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There's probably not a urologic practice that hasn't experienced the impact of no-shows leading to empty slots in your appointment schedule resulting in a decrease in productivity and a loss of income. It doesn't have to be that way. This article will discuss why no-shows occur, how to determine the root cause of the chronic no-shows and solutions to keep you appointment book full, you and your bottom line fat. After reading this article you should be able to reduce your no-show rate from 1-2/day to 1-2/week or even less.

No shows occur when a patient makes an appointment and then fails to keep the appointment and also does not contact your office informing you that they are not keeping the appointment. This is different than a cancellation when the patient, who has an appointment, contacts the office and lets you know that they are not coming and often times will reschedule the appointment. The former is very costly and must be avoided. The latter is creates additional work for the office staff but does not cause havoc with your schedule and severely impact your bottom line.

According to an MGMA survey, no shows can vary from a few percent to as much as 50% in some high volume practices. This can translate to hundreds of dollars lost each day and the loss of thousands of dollars on an annual basis. Proactive practices define the problem and then find a solution that cuts the no-show rate to a tolerable level.

Checking the source of the problem. It is best to start with identification of the problem and determine why so many patients are not keeping their appointments. In my practice, I routinely review all of the charts of patients who didn't keep their appointments. I then ask my patient coordinator or nurse to contact the new patients to determine the reason for the no-show. I have found that new patients who have been given appointments weeks or months prior to their no-show visit have often found another urologist who could see them sooner. When I heard that reason on several occasions, I knew that I had an access problem and created openings in the schedule to accommodate new patients in a more timely fashion. As a result, I was able to solve the new patient no-show problem very easily. On another occasion, I learned that no-shows were commonly repeat offenders. These patients were told after three consecutive no-shows that they would only be given the last appointment in the afternoon. Now if they failed to appear for their appointment, they wouldn't leave holes in the schedule and thus impact my productivity. These repeat offenders were also told in a written letter that if they continue to miss their appointments, they would be terminated and advised to seek their urologic care with another urologist.

On a quarterly basis, we calculate the number of no-shows occurring on a weekly and monthly basis. If we see the numbers drift up, we do a more thorough analysis and we can usually identify the problem. This is the proactive solution that will work and help you keep the problem to a minimum.

What patients are likely to no-show? An MGMA survey identified that the most likely no-show patients are Medicaid and self-pay patients. The other predictor is appointment-waiting time. The longer the time a patient has to wait for an appointment, the greater the likelihood that the patient will not keep hisher appointment. Finally, patients with acute problems need to be seen as quickly as possible. By booking someone with an acute cystitis or painless hematuria three or more days out, you risk creating a no-show. The problem can subside spontaneously before the appointment, or the patient looks for another urologist who can treat himher earlier.

I have lowered my no-show rate significantly by having two time slots, one mid-morning and one mid-afternoon, for urgencies and emergencies as I have noted that nearly every day I have one or two patients that must be seen ASAP. Rather than having them come in and try to squeeze them in between scheduled appointments, I can comfortably see them during these designated appointment times. As a result the last scheduled appointment in the morning and the last scheduled appointment in the afternoon are seen in a timely fashion. Also, my schedule has several time slots that are available for new patients. A new patient even with a chronic condition should have access to your practice within 2-4 days of their contact with your office. Making a new patient wait several weeks risks them calling another urologist for their care.

Technology to the rescue

In the past I used the old-fashioned telephone calls by my receptionist who made the calls at the end of her day. These calls were often made when the receptionist was tired, and as a result, the reminder calls dropped to the bottom of her to-do list. Another problem is that employees often must leave messages on answering machines. Since most patients work from 9 to 5, this makes it difficult for them to confirm the appointment.

A few years ago, I converted to the automated phone systems, which can dial patients in the evening when they're more likely to be home. These systems typically allow the patient to confirm or cancel the appointment with the push of a button. The program then generates a report for the receptionist to see in the morning and any cancellations can be easily filled from the list of patients wanting an earlier appointment.

This automated technology, TeleVox HouseCalls, (www.televox.com and 800.644.4266) has reduced my no-show rate to less than twoweek. The cost is approximately $40 a month, and increases with increasing call volume easily paid for by keeping me more productive.

A caveat: when you implementing an automated phone system, get a recommendation from the company that sold you your practice management software. The automated phone system must interface with your practice management's scheduling software. If it does not interface or bridge, writing a bridge can be costly. Most practice management programs also can generate written reminders that you snail mail. For your computer-literate patients, consider e-mail reminders.

Let patients know the importance of keeping their appointments

All patients should be told the first time they contact the office that the time is being held for them and that you request a 24 hour cancellation. Audreen Dischner, an office manager from Valley Urology in Alaska, notifies the patient's PCP if their patient fails to keep an appointment. She also solves the problem by giving repeat offenders the last appointment of the day, so as not to cause a gap in our schedule or "down time" for the urologists in her practice. New patients who fail multiple appointments with no notification to the office are asked to seek care elsewhere and the referring physician is notified of the dismissal from the practice.

Charging for no-shows

A few urology practices try to discourage no-shows by charging the patient for the time. This has been done for decades by psychiatrists under the guise as being “part of therapy”. This is a tough love approach that I would discourage. This policy sets a sour tone and your referring physicians won't be pleased if they find out, and they will hear about it, if you implement charging your no-shows. These charges are difficult to collect and you may find some patients will leave your practice if you start such a policy. Rick Rutherford, head of practice management at the AUA, recommends charging only those patients who fail to keep appointments for office procedures for which significant productive time is blocked out such as vasectomies and office cystoscopies. Patients should be thoroughly informed of the potential no-show charge when they sign their surgical consent. Mr. Rutherford doesn't believe that a failure to show up for a routine office appointment warrants an additional punitive charge. He says that it generates more gripes than revenue.

A word of advice: if you do charge no-shows, then you better be an on-time urologist otherwise you risk being charged by your patients for time spent in your reception area waiting for you!

The bottom line

Preventing no-shows can be a proactive process. Look at your systems and scheduling processes. Check the access to your practice for new patients and patients with urgencies and emergencies. Identify the obstacles that prevent patients from keeping their appointments. Make every effort to be on time for your patients letting them know that you respect their time. You will be rewarded by patients respecting your time and you will have a more productive and profitable practice.