How to Bill for Missed Appointments

Know the Rules For No-Shows

By Peter Keohane, JD, MPH, CPC
A practice manager recently asked me about patients who miss appointments and how she should address this growing problem. As AAPC members know, when scheduled patients fail to show up for their visits, they cause an interruption in the scheduling process, which creates inefficiency in the office. And more simply, a patient who misses an appointment fails to get necessary medical care. According to an NIH study published in 2004, between four and twelve percent of appointments are missed each year. For mental health professionals, this percentage increases to as much as 50 percent. Is this a significant problem? Undoubtedly it is.
So how should a practice address no-shows? For starters, implementing a procedure to remind patients of upcoming appointments is likely to reduce missed appointments. Another study from the National Library of Medicine found that the most common reason for patients missing an appointment is, “I forgot.” Using a reminder system should reduce this leading cause, however, both manual telephone reminders and mailings can be costly and involve significant staff time commitments. Although an automated system generally provides the most cost-effective system for appointment reminders, these systems are not foolproof. Reasons for automated systems not reaching homes include:

  • No phone
  • Wrong number
  • Disconnection
  • Incompletion of programmed tries due to busy or unanswered calls.

A second recommendation is to ensure the scheduling system accounts for no-shows. For physicians and other medical providers, 15-minute appointments are normal while new patient visits (or physicals) are usually 30 to 45 minutes. When no-show rates or low productivity dictates, double-book the first two 15-minute segments of an hour, leaving the last 30 minutes for new patients or longer visits.

Charge Fees For No-Shows

Many providers charge patients for missed appointments as an additional incentive to show up. Until this year, CMS precluded providers from charging Medicare patients for missed appointments as CMS considered missed appointments part of the overall cost of doing business. This past June, however, CMS published a notice providing new guidance on billing Medicare patients for missed appointments (the transmittal can be found on the CMS website). Under the current guidelines, Medicare allows a no-show fee as long as the practice:

  • Has a written policy on missed appointments that is provided to all patients. (Providers may also want to obtain patients’ signatures to acknowledge receipt of this policy as an extra preventive measure).
  • Ensures that the missed appointment policy applies equally to all patients.
  • Establishes that the billing staff is aware that Medicare beneficiaries should be billed directly for missed appointments.
  • Ensures that charges for missed appointments are reflective of a missed business opportunity and not the cost of the service itself.

Thus, if you do not violate a contract or Medicaid rule, you must charge the fee to all patients for missed appointments. As to what to charge, the amount is left to the provider’s discretion, although there should be some “reasonableness” in selecting the fee. A fee of $35 to $50 appears to be the range most providers use, according to the NIH study.
If a provider elects to charge a no-show fee, it is important to adopt this policy in writing and be certain the patients understand what will happen for a missed appointment. Here is a sample policy:

  • Cancellations of appointments/no-show
  • When you do not show up for a scheduled appointment, it creates an unused appointment slot that could have been used for another patient. It is very important that you call within 24 hours in advance to cancel your appointment.
  • If for any reason you need to cancel an appointment, please notify our office as a soon as possible.
  • On your second no-show occurrence, there will be a $45 charge to your account.
  • After three consecutive no-show occurrences, the practice may elect to terminate our relationship with you.

Under the new CMS guideline, hospital providers must adhere to slightly different rules. In most instances, hospitals are also allowed to charge a beneficiary for a missed appointment as long as the appointment is for an outpatient department, and provided all patients are charged equally. By contrast, hospitals are not allowed to charge a Medicare beneficiary for a missed inpatient appointment (hospital inpatient departments are not allowed to charge a patient for a failure to remain an inpatient for any agreed-upon length of time or for failure to give advance notice of departure from the provider’s facilities).

Terminate a No-show Patient

One final option for patients who continuously miss appointments is to terminate them from the practice. Of course, this is a drastic choice that should be considered carefully, as it could have significant legal consequences. Under most state laws, terminating a patient without proper notice or in the middle of a course of treatment could be considered patient abandonment, which has legal risks. Thus, terminating a patient should be viewed as a last resort measure.
When a patient misses appointments, it costs both the practice (in lost revenues) and the patient (in lost medical care). Minimizing no-shows through reminders and missed appointment fees should help reduce these costs to everyone involved.

Sample Letter to Patient on Missed Appointment

Dear (Patient’s Name):
Our records indicate that you missed your appointment. Please call (our office/the clinic) and we will be happy to schedule another appointment for you. Any time you are unable to keep your appointment, we would appreciate a call in advance from you so that we may cancel your appointment and use the appointment time for another patient.
We are interested in your health care and hope to hear from you soon. If you have any questions, please contact (the office/clinic) at (telephone number).
(Attending Physician)

27 Responses to “How to Bill for Missed Appointments”

  1. Dana says:

    Can we bill a patient for a no show fee if the provider schedules the appointment without confirmation from the patient? For example, the patient received one assessment from the mental health provider, scheduled a follow up visit but didn’t show up, then the provider made two subsequent appointments and just called the patient to notify her of these dates. When the patient failed to show up to these appointments, the provider wants to charge a no show fee. Is this acceptable?

  2. Scott says:

    This isn’t acceptable because the patient did not confirm the appointment. You can’t make appointments for patients without verbal or written confirmation. Furthermore, you could face legal action especially if there is no proof that confirmation was made. In my experience you just send the letters to weed out the patients that cause issues. They are not the individuals you want to work with.

  3. Margie says:

    Scott I work in home care and go to patients homes every week on the same day at the same time. Still there are some that consistently No Show. I don’t get paid for my time or miles for driving to their homes. So yes those people should be charged. I understand people forget on occasion which is why the article recommends one free oops. But for those that once a month “forget” should reimburse me for my time. And I do send reminder texts but often the numbers are disconnected or out of service.

  4. Bri S says:

    I work with a lot of no fault and workers compensation in NY state and was told we can’t charge for missed appointments. I am unable to really verify this. Can you help?

  5. Melanie Askren says:

    I am curious as I had a drs appointment in which I had to split my copay up into two different cards and by the time she was done checking me in I was technically 4 minutes late according to the computer and they are now charging me a $65 late fee (for being late to my appointment) Really can they do that, They do say they want you to arrive 15 minutes prior (don’t most drs) and I have Medicare. Trying to figure out if they are allowed to charge like that.? Indiana

  6. Leena says:

    What CPT would we be able to bill for no-shows?

  7. Kim says:

    I am in California and providing mental health services for Med-Cal patients (in my practice). Would you be able to provide some insight into billing clients for missed appointments. With new clients, I have them complete and sign a form regarding missed appointment/no show policy, clients review, sign; and I give them a copy along with my business card. I also verbally explain the policy at the 1st appointment. To make a long story short, The Department of Behavioral Health sent me a letter, stating that I cannot charge client for missed appointment, and they attached policy DMH letter NO: 02-07 (this is dated 11/19/2002). Also, Title 9, California Code of Regulations Section 1810.365. Any information will be of great assistance.

  8. Sonja says:

    Though this policy of charging a patient for a no show appears to be a good idea to some in the health care field, I do not think it is. Jesus has taught us and teaches us everyday through the story of the widow who made a Lil cake for a prophet using all she had left, that when you do something for him your well will never run dry; Those in the health care field are here to bring God’s earthly healing power to His children: patients; On many times it is not just I forgot but I forgot because of all on my plate in taking care of others e.g those with neurological issues,etc. So I believe that the policy does not over ride the inquiring issue of why are you forgetting?, how might I make it easier and what considerations must I make medically for you the patient. Further, there are times when we the patient wait or have waited hours for providers who needed to stay longer with a patient or were prolonged at the hosputal, and still paid the copay at the same amount; not only a copay but had to call our employer for leave at no pay. The point is we all have issues and must work together. For I hate to hear of someone staying away from the very people needed because the no charge fee and the copay fee for the new appointment was unaffordable,landing the patient in a dire state medically;

  9. Stephaie says:

    I am in WV and my provider states that I have to pay 250.00 (yes, two hundred and fifty dollars) if I miss an appointment? Is this legal? I have never signed anything to that effect and was only told over the phone please advise

  10. Gretchen Glass says:

    A question: I received a bill for a psychiatrist. I made a new patient appointment with a nearby doctor. They did call to remind me a few days before but due to a work meeting, I actually forgot the day-of. I did not complete the paper work (psychological history) but when I dropped in, I did allow them to copy my insurance cards and driver’s license. I received a bill for $375 for the missed appointment. Am I technically even a patient? They don’t know anything about me except the my name and address. Is there any legal standing for me not to pay?

  11. Paul says:

    It boils down to, which are you? A doctor? Or a business person? If business comes first, then by all means charge those flaky patients of yours a fat fee for negatively impacting your profitability. Particularly in the mental health field, many patients struggle to keep appointments because of the illness they are seeking treatment for. To fine them, and then drop them, without even a referral to another practitioner, is offensive and unconscionable.

  12. Patrick Baker says:

    So what does the patient get if the doctor cancels (less than 24 hours before appointment) or is a no show to scheduled appointment? Can he/she charge the doctor a fee?

  13. Lisa M Lesher says:

    I understand the frustration of many a patients. However, at the same time, I would like for each of these pts to go to work for an hour without getting paid. Now repeat this 10-15 times in the same week. So if we, as providers, have 10 patients that no-show for that wk, we are literally not getting paid. Our children are not getting paid or benefiting from our payments. I would never ask one of my pts to work every wk but not get paid for 10 of those hours! We may be providers, but we are still making a living. Believe it or not, family practice providers are not making great money any longer. This is why everyone is going into specialty work. If we cannot make a salary because of no-shows, pts will lose out as we have to close our practices for corporate-run offices.

  14. JackieO says:

    I work for a one doctor practice. Our fee schedule is stuck in 2008! Our no show fee is in writing. Our patients are reminded 2 days out. We have at least 2 no sows a day, very costly. The rent, lights and staff salaries still have to be paid. Once we charge our $30 no show fee, we almost never see the patient again. That’s also why we have to double book. We have had up to 4 not show. Patients do not care.

  15. Joey Gochnour says:

    I run a dietitian Private Practice all by myself. I have patient sign my forms electronically ahead of time and they are notified that they have a $75 no show fee, which is half of my rate I Bill to insurance. They are also notified in an email confirming the appointment as well as a calendar invite that reminds them 2 hours and two days before their appointment. I still have people who either cancel 20 minutes before their appointment or just don’t show up. When called they make up a bullshit reason (I’m not sure if any reason would be valid at that point). I have also had patients cancel right before their appointment because they “just found out” they need a referral to see a specialist. People still don’t pay the no-show fee. Some of them try to argue their way out of it. I just choose not to see those patients and tell them they can go see somebody else in town. If they wanted to see me they shouldn’t waste my time. As others have stated, I still have to pay for an office expense and cost of being in business and not making money that day. I showed up to work and should be paid. I’ve had literally 8 to 10 patients in the past week not show up, late cancel, or cancel in time. Only about four of them actually cancel in 24 hours notice. Even with 24 hours notice, it is not always possible to schedule somebody to fill the time. So we just make less money. No show patients are a true threat to health care practice. I have to work a part-time job in an unrelated field as a healthcare provider specialist in order to make ends meet. I make a fraction of the money of the people screwing me over. I have no problem charging them no show fees and then sending them to collections. Some people don’t even pay the visit cost after service is rendered.
    Patients who don’t see how this works have no idea how a business works and are too focused on their needs and not others. Something needs to be done about this because this is a huge problem.
    That said there should be some enforcement of what a fee can be. I think $75 or half my rate is reasonable. I don’t think $375 as reasonable as some others have posted. People only charging $30 it’s also not enough because that’s like what an employee is paid who is giving benefits, when we pay for our own benefits as self-employed people as well as our own expenses and overhead.

  16. Cindy says:

    Can we refuse to re-schedule a patient who no-shows for their first appointment?

  17. Joey Gochnour says:

    Why wouldn’t you be able to? They didn’t follow policies, they are not good to work with. You can’t just fill up your practice with flaky people. If they want to reschedule, they ought to admit their fault by paying the fee if they truly want to work with you. Otherwise, there are plenty of others in town to take their irresponsible, selfish style.

  18. Erin says:

    I made an appointment as a new patient but couldn’t be seen for four months. Changed my mind two days later and called back and canceled. Then about a week after i would have been seen i get a missed appointment bill for $60. I wrote and told them i had canceled. And two weeks later i receive a second bill. I have sent it to my attorneys. I was never told of any cancelation policy but i canceled anyway. I work hard too and have now had to spend my time to deal with this and incur legal fees. I feel any rules or laws on the subject should make it mandatory it should be in writing signed by patient and the patient has to be established. I do not want my name on their books at all and feel this is even crossing into HIPAA violations. I respect doctors and agree they should be paid for their time but it has to be fair and clearly defined for the patient.

  19. Judith Burks says:

    My sister sees a therapist once a week and has been for several months.. She would like to visit with me. Her therapist states that she must charge her $25.00 each visit she does not show.
    My question; if she (my sister) gives the therapist as much as a weeks notice. Can she charge my sister this cost? This would not be a no-show right?

  20. Richard says:

    You are getting paid for a service. If you don’t provide that service you should not expect to be paid. This is common sense and basic business practice.

  21. Jeff Schultz says:

    Is there a difference in charging for a no-show in a non-for-profit setting vs for profit setting??
    Can someone provide me the ruling if there is one that specifies either way?

  22. GM Stratton says:

    What recourse does a patient have when the doctor who misses scheduled appointment. Patient have had to wait as much as 1:30 minutes for schedule appointment this is in addition to arriving 25:00 minutes early
    Patients have duties an responsibilities as well as physicians having to wait one to two hours per visit is not acceptable

  23. Tuwana Clarke says:

    Can Medicaid patients be charged for missed appointments as well?

  24. Anne Jackson says:

    People in practice and psychotherapy clients need to realize that therapy appointment agreements are more like rental agreements than they are like hairdresser appointments. There is no “drop in when you want” form of therapy that does anybody any good. If a therapist is agreeing to work with a client ongoingly, which is typically on a weekly basis for a period of time, he or she has to ‘rent’ out that time in the therapist’s schedule to the client, and the therapist must hold it open for the client on a weekly basis, and is not free to take on another client in that time just because the client cancels. Rarely are clients coming in to see therapists for a one-off appointment. Because the therapist is not free to take on another client and use that time any more than the landlord is free to rent out a space on a temporary basis just because the client is on vacation, the therapist has every right to charge for the missed time. Do you pay your landlord whether you are using your apartment or not? Then you should pay your therapist whether you are there or not, at least as long as you are in agreement to meet weekly for a period of time to accomplish some goal of therapy.
    The problem as I see it is that everybody – including insurance companies – think that therapy is a fee for service business when it is not. There are many activities that go along with offering time for psychotherapy clients that are not directly reimburseable yet must be done. We need to agree and then educate the public as well as our third party payers, and start charging retainer fees as opposed to hourly fees.

  25. Sunil Shelar says:

    Is there any CPT code for no show or cancelled appointment? Please advise

  26. Marlynn Murrey says:

    I would use 99999 or some other unlisted code. Remember, you are NOT billing insurance, only the patient who no-showed.

  27. Danica says:

    In the state of California, I work for an outpatient therapy company who contracts with myself as an independent contractor. When a patient no-shows for one of my sessions, I don’t get paid anything by the contracting company. I had signed a contract a year ago, agreeing to not receive no-show pay as the company would not be attempting to collect such from their patients due to losing their business. However, as of a month ago, I found out that the contracting company has started to collect no-show fees from my patients but don’t pay me any of that money. Is this legal?