Friday, October 17, 2008


Still struggling with what my policy should be for clients who don't show up for appointments, or cancel at the last minute. This week a new client didn't show up for his second meeting with me; I called him, we rescheduled, but he didn't show up for that one, either. He called me later, rescheduled again, and finally made it (albeit rather late) on the third try. This is frustrating.

So far, the policy has (on paper) been a 50% charge for cancelations with less than 24 hours notice, or 75% if you just don't show up at all and leave me waiting around the office for you. Unofficially, there's been a one-time-per-person-per-year general amnesty (based on the Smallish City's one-parking-ticket-annually-forgiveness), and beyond that I've also doled out freebies for various "good excuses" (sick kids, stuck in foreign airports, car accidents, dog ate homework, etc.) But as I think about it, these really add up into the many thousands of dollars out of my income, over a year. In light of the Wall Street Journal's suggestion that we may soon be working for $5 an hour, this deserves consideration. Also, I really don't like having to judge whether people's excuses are "good" or "bad".

I had dinner last night with nurse practitioner friend B. and her husband M. B. works in a private psychiatric clinic. The policy there is-- you miss appointment, you pay $75. No discussion. And, if you need a prescription called in between appointments, that's $25 (no charge for this at the Turbo clinic.) Another local shrink I know has a policy that you have to pay ahead of time for an initial evaluation-- and if you don't show up for it, he keeps your money and doesn't allow you to reschedule. Harsh, but apparently effective.

It's all complicated by the rather large proportion of my clients who don't actually pay their own bills. In some cases, one person is the patient, a second person (e.g., mom) is responsible for getting patient to my office, and a third person (e.g., divorced out-of-state dad) pays the bill. Then it gets messy.

Ah well. At least my just-canceled 8:30 appointment today has left me time for coffee and blogging this morning.


Blogger marcia said...

You need to charge for no-call, no-show (or less than 24 hours notice), but let your office staff (do you have one of those?) do the dirty work of explaining the situation and collecting the fee. This keeps you from seeming like the bad guy, since it's an "office policy" and you haven't become directly involved. That way it doesn't damage your relationship with the patient, and you don't get taken advantage of so much, either (or lose as much income).

That's how my pdoc handles it, and I've only missed two appointments in 10 years, so it must be effective, right?

10/17/08, 9:42 AM  
Blogger Turboglacier said...

"your office staff (do you have one of those?)"

Uh, yeah, sure I have one of those. Same guy who vacuums the carpet... and takes out the trash... and does the scheduling... and waters the plants... and writes the prescriptions... and decides when I can take vacation...

10/17/08, 9:53 AM  
Blogger The MSILF said...

The clinic you describe, where they are so stringent...well, that approach makes me wonder about...hmm, how do I phrase this? It gives me sort of an icky feeling about the docs running it. I do understand it and all, but still, it's not the money part of the policy but rather that it's so important and spelled out and complicated that, to me at least, gives the impression that that's the most important thing for them, that their heart isn't in it.

How do you bill? Do you do formal bills or just close accounts with clients once every several sessions? If you write a bill with dates of sessions and stuff, can you just add the missed one in there?

That said, if you're in private practice, don't you have much more leeway about "firing" patients who are constantly troublesome about this? And I don't mean ones who really have a hard time paying...I mean the ones who for whatever reason aren't courteous about it.

That said, my shrink is really reasonable, no official policy, or at least not one I've heard of, and I have such an erratic schedule that I know that if I NEED to cancel I can, and he even offers to let me when I've had a horrific call night and am exhausted. I consider that a very generous, but unnecessary gesture.

And phone calls - I can't believe there's a PRIVATE practice that makes a deal out of prescription phone calls. Not long, talking ones...but prescription ones...that seems ridiculous.

10/17/08, 10:06 AM  
Blogger marcia said...

"Uh, yeah, sure I have one of those. Same guy who vacuums the carpet... and takes out the trash... and does the scheduling... and waters the plants... and writes the prescriptions... and decides when I can take vacation..."


I see your dilemma, then.

10/17/08, 11:04 AM  
Blogger Claire Colvin said...

Be careful that you're not teaching your clients that the exception is normal behavior. If you always let clients cancel without penalty what you see as extending grace they will assume is business as usual and will have no reason to alter their behavior.

In my RMT's office there is a sign that says "Your appointment time has been reserved for you. If you need to cancel we require 24 hours' notice. If notice is not given 24 hours in advance, the full fee of the session will apply." I have never found that to be uncaring, merely practical. The practice is very busy. Given the 24 hours' notice they can always fill an open time slot. If I don't give them that I rob them of an hour's work. In 6 years of monthly visits to the clinic I have missed 2 appointments. Both were for migraines.

It's unfortunate that there has to be a money element to helping people, but if you put yourself out of business, you won't be able to help them at all.

10/17/08, 12:47 PM  
Anonymous girltuesday said...

hey I've said it before & I'll say it again: GT Collections Agency. Sick your lawyer on 'em, yo!

10/17/08, 10:06 PM  
Anonymous Anonymous said...

My therapist made it clear from the very beginning that he needs 24 hours notice to cancel an appointment, or he'll charge 50 Euros because he couldn't otherwise use the time to work. He made a big song and dance about it, but to me this was obvious anyway, and I've never cancelled at short notice. Strangely, I did have a number of dreams where I suddenly couldn't find the therapist's office any more, and was stressing out about the 50 Euros!!

From my psychiatrist I got my perscriptions between appointments for free, but then I only saw her once every three months or so. I did once arrive quite late because I had forgotten an appointment, but she was so busy, and always running behind schedule, that she had plenty of patients to fill that time slot in with. Also, my appointments with her were only 10 - 15 minutes long.

To make ends meet, would it be possible for you to work for the state part-time, while you build up your private practice?

10/18/08, 2:46 AM  
Blogger dweller on the threshold said...

I don't think it's unreasonable at all to charge for missed appointments that aren't canceled with enough notice and I'm only a patient not a practitioner. I'm not one to miss appointments but recently my therapist (who's a LCSW) scheduled me for a different time and I entered the wrong time in my Outlook calendar (which runs my life) so I was a no show. He called about half way through the appt to ask where I was. I had a pretty intense reaction to missing the appt (we're working on a lot of attachment issues) and ended up calling him back. As far as I'm concerned, I am expecting that appointment to show up on my bill. He reserved that hour for me and I used it. I just didn't use it by showing up.

And it's not a sign of not caring. I take a great deal of pride in the work that I do, and really care about how it turns out and it has nothing to do with helping people out the way therapy does, but I don't do it for free. I expect you like to eat regularly and have heat in your home like the rest of us. I do like your policy of a one time pass, and I can even understand making exceptions for the circumstances (car accident, sick kid etc.) but I think you are generous to do so.

10/21/08, 10:20 AM  

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