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.

Certified Physician Practice Manager CPPM

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)

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13 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.

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