September 1, 2013 Columns

In Private Practice: No More No-Shows

Clear policies—and sometimes penalties—will help reduce last-minute cancellations and improve your bottom line. Here are some suggestions.

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If you are working in a school system or hospital, a student absence or a cancelled patient may bring a sigh of relief—it gives you time for that endless paperwork or those extra job requirements. But for those of us in private practice, cancellations and no-shows are perhaps the toughest of private practice challenges, and are more likely to bring on anxiety, frustration and financial woes.

How do you successfully run the business and maintain scheduling continuity while upholding ASHA's code of ethics? How do you structure your practice to best serve your revenue, while simultaneously maintaining compassion and professionalism?

In Private Practice

Here are some suggestions to help private practitioners set policies that are fair to clients and to the business.

Setting and acknowledging policies

The first step to decrease cancellations and no-shows is to have solid office policies in place, and to have all clients sign them before an evaluation takes place or treatment begins. If your expectations are clear and in writing, you can improve client attendance. By signing the policy, clients agree that they, and not the insurance provider, are responsible for fees associated with violating the policy.

I recommend implementing separate policies for evaluation sessions, treatment sessions and make-up sessions.

  1. Evaluation policy
    When your office schedules an evaluation, collecting a deposit from the prospective client will drastically decrease no-shows. You may want to consider taking credit cards for deposits; clients could, however, dispute these fees with their credit card company. Checks or money orders are the best form of deposit, because you can deposit the payment before the evaluation takes place. 
  2. Treatment policy
    Most medical practices follow a 24-hour rule for cancellations, and yours should be no exception. For treatment appointments, it's important to distinguish between emergency and non-emergency cancellations to avoid abuse of "sick" excuses. The wording in the cancellation policy must leave no room for interpretation. Although you want to be compassionate about illness and true emergencies, you also need to let clients know you won't accept multiple cancellations for social activities.
  3. Make-up session policy
    A make-up policy will help increase attendance—generally, when clients know they need to reschedule their missed session, they are less likely to cancel for non-emergency reasons.

Make-up sessions protect revenue, improve progress levels and keep schedules flowing. Some clinicians leave a few slots open each week to allow for make-ups, while others use cancelled appointments for make-ups. If you choose the second option, you can e-mail (blind copy) the availability of the slot to clients who need a make-up appointment. Using blind copy allows for privacy and is compliant with federal privacy regulations. You can fill your opening and subsequently protect revenue, turning a cancellation from a loss into a session with another client.

Overall attendance

To maintain a lucrative and smooth-running private practice, you need to keep very detailed records of attendance, cancellations and make-up arrangements. If you have established a maximum number of allowed cancellations, the records provide evidence that the client has reached that limit.

Each practice maintains its own cancellation limit, but most use a baseline of 15 to 25 percent, and clients who exceed that limit risk losing their treatment slot.

If you need to dismiss a client for poor attendance, you will want to do so within the framework of the code of ethics. In your policies, stipulate a time frame in which notice will be given, and expect the same courtesy from your clients.

Enforcement

It's one thing to establish clear policies, and quite another to enforce them. Here are a few simple but effective suggestions.

  • Notice. Each time a client cancels, remind the client of your policies and his or her standing by phone, e-mail or written letter. For example, if a client rarely cancels, you could state, "You have excellent attendance and I am sure we will schedule a make-up session soon. I hope [name of patient] is feeling much better and I look forward to seeing her on (date)." This notification alerts your client that you are monitoring attendance and that you are concerned for his or her well-being.
  • Review of office policies. At least twice a year, provide visual reminders of your policies. You can hang them in your waiting room or rest room or send e-mail reminders.
  • Renewal. Ask clients to review and sign office policies annually.
  • Enforcement. Every client deserves a second chance, but never a third. If there is a violation, the client must pay the associated fees. Although cancellation fees will not hold up in a collections court, your policy is a contractual agreement signed by the client, and the client must pay the fee to hold a weekly slot in your practice. If you collect a fee for the missed session, give your client a receipt for the cancellation fee rather than a bill, because you are not providing a service that is insurance-reimbursable.
  • Diffusion of authority. If you have an office manager or assistant, let that person be the bearer of bad news. Many clients, however, will try to appeal to your emotions. Do not personalize this aspect of your business. Use simple statements such as, "My accountant/lawyer/office advisor insists that I enforce my policies. I am certain you read them when you started treatment. I apologize for any inconvenience."

Although some may view strict policies as difficult or inflexible, most fee-for-service businesses follow similar models. Your ethics obligate you to ensure maximum progress, and poor attendance is certain to have an effect on treatment outcomes. Your primary concern is, of course, care for the client, but you have a right to fair compensation. By setting parameters in the beginning, it is acceptable to make your clients accountable.

Robyn Merkel-Walsh, MA, CCC-SLP, is a private practitioner, a school clinician for the Ridgefield (N.J.) Board of Education and an instructor for TalkTools®. She is a member of the American Academy of Private Practice in Speech Pathology and Audiology. robynslp95@aol.com

cite as: Merkel-Walsh, R. (2013, September 01). In Private Practice: No More No-Shows. The ASHA Leader.

Policies 101

Office policies should be direct, easy to understand, and clear. Here are some examples.

Sample evaluation cancellation policy

Please be advised that you must send a deposit of $_ within seven days of booking your appointment to hold the time slot. This fee is to review your records and communicate prior to the evaluation. If you must cancel your appointment, you must do so 72 hours (three days) before the appointment to receive your deposit back (minus the time already taken to review your files, records, etc.) If you fail to cancel your appointment within that time frame or if you miss the appointment, you will forfeit your deposit.

Sample treatment cancellation policy

Non-emergency cancellations require 24 hours' notice. Non-emergencies include vacations, preplanned medical appointments, family events, parties, sports events, lack of babysitter or anything that is not designated as "emergency" (see below). The session must be canceled no later than 24 hours before the appointment. If non-emergency cancellations become excessive, the client may lose his or her weekly slot in the clinician's schedule. If the session is not canceled with 24 hours' notice it will be billed at $_.

Emergencies require notification by (set time). Emergency cancellations are accepted only for illness, illness of a family member or death in the family. These sessions must be canceled by (set time) on the day of the appointment. Please do not come, or bring your child, to the office with a fever, strep, unidentified rash, diarrhea, vomiting or any highly contagious illness. You or your child must be fever-free for 24 hours prior to the session. If you or your child arrives ill, you will be dismissed and charged for the session.

Sample make-up policy

We offer make-up sessions, as they are in the client's best interest. Make-up slots are offered for inclement weather, illness and pre-arranged vacations/holidays. Make-up sessions are not offered when there is a violation of the cancellation policy. For example, if you are charged for a no-show, we will not reschedule that visit. Make-ups must be attempted for all holidays, vacations and cancellations. Failure to schedule make-ups is considered a violation of policies.

Sample make-up session e-mail

FROM: robynslp95@aol.com
BCC: client1@aol.com, client2@aol.com, client3@aol.com
RE: Session Opening 6/26/13 @1:30 p.m.

Due to a cancellation, I have an opening 6/26/13 at 1:30 p.m. If you are on the wait list for a make-up time and would like to attend this session, please contact me ASAP.This is a first-come, first-serve basis. Thanks.

Sample overall attendance policy

Because this office holds a time for your session, you are essentially promising to fulfill that slot. We take careful attendance. If you exceed a cancellation rate of 25 percent or higher you will receive a written notice that your slot is in jeopardy, especially if you do not schedule or attend make-up sessions. This policy includes emergency, non-emergency and vacation cancellations.

Sample dismissal policy

If you plan on discontinuing services for any reason, you must give this office four weeks' notice or you will be billed for the missed sessions. This office must also give you 30 days' notice if treatment will be discontinued for breach of attendance policy.



  

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