Missed and canceled appointments, referrals not completed
Managing patient appointments is an important function of any office practice. A poorly managed appointment process poses not only a risk to patient safety and continuity of care but also a risk to the practice’s financial well-being.
Policy: Practices should determine their appointment management system. Once the process has been defined, a policy should be written, and all staff members involved in the process should receive education on the steps in the process and the importance of these steps to ensure patient safety and the practice’s financial stability. The following steps should be included in the process.
Appointment Reminders: Appointment reminders are an important aspect of the appointment management process. Patients should sign a statement agreeing to receive reminders. Reminders should not contain protected health information. Phone calls, automated messages, text messages, or the patient portal can be used to send appointment reminders. Generally, reminders are scheduled for 1-2 days prior to the upcoming appointment. Reminding patients of their appointment helps to ensure they will keep the appointment and will give them the opportunity to cancel and re-schedule their appointment, thus opening up appointments for other patients.
Patient Follow-up: An important aspect of the appointment management process is ensuring that patients schedule their follow-up appointments. After completing their visit with the provider, patients should be instructed to stop at the front desk to schedule their follow-up appointment as directed by the provider. If the patient is unable to schedule their follow-up appointment at check out, there should be a process in place to continue contact with the patient until the follow-up appointment has been scheduled.
No-Shows: When a patient does not keep their appointment and fails to notify the practice, this could mean that the patient simply forgot the appointment or it could mean that the patient has decided not to keep the appointment. Inform new patients of the practice’s policy for no-show appointments. Does the practice require a 24-hour notice for cancellations? Will there be a charge for no-show appointments? How late can a patient be before their appointment is canceled? Be sure that patients are aware of your practice’s policies. When a patient does not keep their appointment, the following steps should be taken:
- Notify the provider of patients who miss or cancel appointments. This allows the provider to direct additional follow-up activity.
- Follow up with the patient as directed by the provider. Make at least three attempts to contact. Include the following steps in the process:
- The initial attempt would be the courtesy contact mentioned above.
- The second attempt may also be a phone call or a letter sent by first-class US mail.
- Because receipt of voicemail messages by the patient cannot be verified, proceed to send a written notice if the second phone call does not result in direct contact.
- Document all attempts in the patient’s medical record.
- For missed or canceled appointments where serious consequences could arise as a result of lack of follow-up, the letter sent in the third attempt should outline the possible medical issues that may arise from not returning for treatment. This should be sent certified, return receipt requested mail.
- If the patient refuses a certified letter:
- Note the refusal in the patient’s medical record.
- Place the unaccepted letter in the envelope in the medical record, or scan a copy of the unaccepted letter and place it in the patient’s electronic health record.
- Make a copy of the letter.
- Send the copy back to the patient in a plain envelope with no office practice identifiers.
Cancellations without Rescheduling an Appointment: When a patient cancels an appointment without rescheduling another appointment, the provider should be notified. Follow the steps outlined above for no-show patients in order to ensure that patients receive the appropriate continued care.
Referred Patients Who Fail to Schedule or Miss Initial Appointment: Practices should have a process in place to track referrals to ensure continuity of care. If a referred patient fails to schedule an appointment or does not keep their initial consultative appointment, the specialist should notify the referring provider that the patient did not make or keep their appointment.
Patients with Repeated No-Shows or Cancellations: While missed appointments can be frustrating for providers and office staff, they can also identify issues with patient compliance with treatment plans. When a patient cancels or does not show up for an appointment, it could be a sign of concerns the patient might have, for example: do they understand their treatment plan, are they having difficulty affording their medication, are they having difficulty losing weight, quitting smoking, or exercising? Could they be concerned about the provider’s reaction to their lack of progress on treatment goals? Providers can use missed appointments as an opportunity to address the concerns that might be causing the patient to miss their appointments, utilizing resources such as care coordinators when available. If despite the provider’s best efforts, the patient continues to miss appointments, it might be necessary to consider terminating the patient from the practice. See our practice tip: Termination of Physician-Patient Relationship.
Patient Portal and Appointment Management: A patient portal may offer options designed to facilitate appointment management. When using a patient portal:
- Verify that the patient’s appointment view is enabled so they may view all of their appointments on the portal.
- Verify that the patient’s referral appointments are listed in the patient’s appointment view.
- Enable a standard patient response to their attempts to schedule, reschedule, or cancel an appointment via the patient portal. Require a care team member to review all patient attempts to schedule, reschedule, or cancel an appointment and require an email acknowledgment confirmation of the patient’s requested actions or alternative suggestions.
ASHRM: Physician Office Risk Management Playbook 2016
Medical Mutual Insurance Company of Maine's "Practice Tips" are offered as reference information only and are not intended to establish practice standards or serve as legal advice. MMIC recommends you obtain a legal opinion from a qualified attorney for any specific application to your practice.