Of all the headaches inherent in a private medical practice, few are more frustrating than patients who make appointments and then fail to keep them.

No-shows are a problem for all physicians but especially for dermatologists. In one study, the no-show rate in dermatology offices averaged 10% – almost double the average for medical offices as a whole.

Why the higher rate? One reason is a lag between appointment and visit. Many dermatologists are booked well in advance, so, by the time the appointment arrives, some patients’ complaints will have resolved spontaneously, while other patients will have found other offices willing to see them sooner. Another reason is lack of insurance coverage. Studies have shown that the no-show rate is highest when the patient is paying out-of-pocket for the visit.

But the biggest reason is probably the absence of a strong physician-patient relationship. Perhaps the patient sees a different doctor or physician assistant at each visit and doesn’t feel a particular bond with any of them. Some patients may perceive a lack of concern on the part of the physician. Others may suffer from poor communication. For example, patients frequently become frustrated that a chronic condition has not resolved, when it has not been clearly explained to them that such problems cannot be expected to resolve completely.

Whatever the reasons, no-shows are an economic and medicolegal liability. It is worth the considerable effort it often takes to minimize them.

Deal with simple forgetfulness by calling your patients the day before to remind them of their appointments. Reasonably-priced phone software is available from a variety of vendors to automate this process. You could also hire a teenager to do it after school each day.

Whenever possible, use cell phone numbers for reminder calls. Patients often aren’t home during the day, and many don’t listen to their messages when they come in. Patients who have moved will often have a new home phone number, but their cell phone numbers will be the same.

Decrease the wait for new appointments. Keep some slots open each week for new patients, who will often “shop around” for a faster appointment while they’re waiting for an appointment they already have elsewhere.

If your no-shows are incorrigible, consider charging them. One increasingly popular mechanism is a fee ($20 seems to be popular) that must be paid at the time of the next appointment before being seen. Some patients will respond to that by never showing up again. Fine. You need to reserve your appointment slots for patients who plan to keep them. Those more contrite will pay and, hopefully, learn their lesson. Give your receptionists the power to override the charge since there are, obviously, legitimate reasons for missing an appointment.

One physician in my area told me he seldom actually collects the fee, which is okay with him. “After all,” he said, “the purpose is not to generate income. It’s to encourage patients to keep their appointments.”

If you go this route, be sure to post notices in your office and on your website clearly delineating your policy. Emphasize that it is not a service fee and cannot be billed to insurance. Remind patients about it during reminder calls. If you have a high no-show rate for cosmetic and other noninsurance procedures, consider collecting a nonrefundable deposit in advance.

Above all, seek to maximize the strength of your physician-patient relationships. Try not to shuttle patients between different physicians or PAs, and make it clear that you are genuinely concerned about their health. Impress upon them the crucial role they play in their own care, which includes keeping all their appointments.

In our office, significant no-shows (for example, a patient with a melanoma who misses the visit for re-excision) receive a phone call and a certified letter, and their records go into a special file for close follow-up by the nursing staff.

All missed appointments should be documented in the patient’s record – it’s important clinical and medicolegal information. A second missed appointment should prompt a written warning that measures will be taken if it happens again. Make sure to spell out what those measures are, and stick to them. Habitual no-shows should be dismissed from your practice. You cannot afford them.

Dr. Eastern practices dermatology and dermatologic surgery in Belleville, N.J. He is the author of numerous articles and textbook chapters and is a longtime monthly columnist for Dermatology News. Write to him at dermnews@frontlinemedcom.com.

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