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CMT Industry Analysis, “How Concierge Doctors Are Taking A Lead In Ending Fees For Missed Appointments, Immunization Record Copies and a Copy of Their Last Sports Physical Form”

By Michael Tetreault, Editor-in-Chief | Nine (9) Medical Article Sources Listed Below [End]

SUMMER 2018 / Atlanta, GA USA – Patient Cancellation Policies. For Patients, these surprising fees are also known as the barb on the wire or the thorn in our side.

For Physicians today, in 2018 alone, it’s estimated that no-shows cost the healthcare industry more than $150 billion a year[2].

Typically, when a Patient sees an extra $25, $50 or in some practices, $100 add-on charge their jaw tightens and their face gets red. To say most patients are understanding and feel the justification for the fee is acceptable would be an exaggeration.

infog concierge medicine tech“In my opinion, I think charging a fee(s) for missed appointments is uncalled for,” says Barbara, in our request for an interview in June 2018. “What about when the doctor (lets call him/her Dr. LateFee) is late for a patient’s appointment who was on time? A Patient does not get to charge the doctor for being late. A Patient is not allowed to charge Dr. LateFee when they arrive for their appointment on time only to find out he/she had to leave. Dr. LateFee and his/her staff should be jumping for joy when a patient is late or missed their appointment. This gives the Doctor a little time to catch up or see the next person who might already be waiting for their appointment. Why are we, as patients, smiling with glee and surprised when our Doctor is actually on time for an appointment, when they should have been walking into the room on time, early and smiling, in the first place?”

Life happens, I get it.

So, in the spirit of transparency, I’ve missed an appointment or two in my day. I’ve debated the merits of a missed appointment charge or two and I’ve learned my lesson. None of us are perfect and I’m certainly man enough to admit that I make mistakes. Fast-forward to present day and licking my wounds and realizing I won’t make that mistake again I say “Whoah, thank goodness they understand … and they had enough grace to waive the fee.” Today however, I usually try to call the office a week ahead, few days before or as soon as I know I will not make the appointment to reschedule.

infog_2017“I have a policy of $50 no-show fee, but have not enforced it,” said one Direct Primary Care Physician.

In 2018, Concierge Medicine Today and our sister publication, The Direct Primary Care Journal examined the patient cancellation policy trend. Concierge Medicine Doctors, known for being some of the earliest adopters of creative healthcare delivery concepts and Direct Primary Care clinics, commonly known to have a direct, cash relationship with their patients are just two of the healthcare delivery models operating successfully today that are doing away with missed appointment. In an online 2018 poll we found that 96% of Concierge Medicine and Direct Primary Care Doctors stated …

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According to Concierge Medicine Today, In Concierge Medicine, missed appointments and cancellations are nil-to-none.

  • 64% of Concierge Medicine Doctors polled in 2018 stated “Penalty? We would do no such thing to our patients.”
  • 27% of Concierge Medicine Doctors said “Because we have a relationship-oriented practice, missed appointments have declined more than 95%.”
  • Additionally, 84% of Concierge Medicine Today Physician readers polled in 2018 said “Before I started my Concierge Medicine practice, I Had Time to Ask Less Than 5 Questions per patient, per visit. Today, In My Concierge Medical practice, I Can Ask/Have Time to Ask No Less Than 20+ Questions per patient, per visit and my average visit lasts between 45-90 minutes with each patient.”

“As a house call MD, I have never had a missed appointment I text before heading over,” said one Concierge Medicine Physician.

According to The DPC Journal, In Direct Primary Care, missed appointments and cancellations are nil-to-none.

  • 58% of Direct Primary Care Doctors polled in 2018 said “Penalty? We would do no such thing to our patients.”
  • 34% of Direct Primary Care Doctors also said “Because we have a relationship-oriented practice, missed appointments have declined more than 95%.”
  • Additionally, 76% of Direct Primary Care Journal Physician readers polled in 2018 said “The average wait time in my practice is less than 10-minutes. In 2015, Direct Primary Care Journal Physicians were asked the same question and we found that 61% of Direct Primary Care offices had less than 10-minutes wait-times.
infog dpc 4-3

“There are differences …and regardless of what you hear, you must choose the one that works for your career. Both have great patient and physician benefits.” INFOGRAPHIC … (Source: Concierge Medicine Today, 2007-2018)

“When comparing 2015 DPC wait-times to 2018 DPC wait-times inside more than 100 Direct Primary Care offices we are seeing a 15% decrease in patient wait-times (76% in 2018 ≤ 10-minutes vs. 61% in 2015) in the under 10-minute time-frame.”

  • 67% of Direct Primary Care Journal Physician polling respondents in indicated that they spend between 31-60 minutes with each patient during every visit.

Can a doctor charge me for copies of my medical records or x-rays? Yes, pursuant to Health & Safety Code section 123110, a doctor can charge 25 cents per page plus a reasonable clerical fee. For diagnostic films, such as an x-ray, MRI, CT and PET scans, you can be charged the actual cost of copying the films.[7]

The US National Library of Medicine National Institutes of Health surveyed 73 hospitals across the US, with a geographic concentration around Boston, to determine their policies about fees for copying medical records and the expected time it takes to fulfill such requests. Fees range very widely, from $2-55 for short records of 15 pages to $15-585 for long ones of 500 pages. Times also range widely, from 1–30 days (or longer for off-site records). A few institutions provide records for free and even fewer make them accessible on-line.

According to an article in the Daily Breeze, updated in September 2017 entitled Ask The Lawyer: Can a doctor’s office charge me for missing an appointment? — The article notes … 

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Missed appointments have three impacts: (1) staff time involved with follow-up, such as rescheduling, (2) lost time that was allotted to that patient, and (3) no revenue from the no-show. American Medical Association policy says a doctor may charge for a missed appointment – or for failing to cancel 24 hours in advance – if the patient is fully advised that such a charge will be made. However, research indicates there is no CPT code for missed appointments. (CPT means current procedural technology, used by the health insurers to evaluate reimbursement.) So, is such a charge enforceable? If you have signed something that clearly mentions the policy, the doctor has a stronger argument. Otherwise, it comes down to notice to you, your justification for canceling, and if the doctor’s office is serious. If it is not a two-way street – that is, you don’t show and you get charged, but the doctor’s failure to show has no impact – that would seem rather suspect. Research further indicates Medicare policy allows physicians to make such a charge, but Medicare will not pay for it. Bottom line, talking things out may work.[6]

Let’s take our analysis a step further.

According to this article from PatientPrompt, if a pediatric practice sees 100 patients a day at an average appointment cost of $125, with a 13% no-show rate, the practice would lose $32,500 every month!

And, lets not stop there. Let’s keep digging.

According to LumaHealth, No-shows are costing your practice a ton of money. You’re not just losing money in missed appointment revenue, though. You’re also losing money in your staff’s valuable time.[4]

Advisory Board[3] noted in 2012 … Last-minute surgery cancellations and patient no-shows cost hospitals millions of dollars each year, according to a study presented at the American Society of Anesthesiologists‘ annual conference. For the study, Tulane University Medical Center researchers examined records for 4,876 elective outpatient surgeries scheduled at the New Orleans medical center in 2009. They found that 6.7% of the scheduled surgeries in 2009—or 327 surgeries overall—were cancelled, costing the medical center nearly $1 million.


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According to the study:

  • More than 30% of the procedures were cancelled because patients did not arrive at the hospital at the correct time; and
  • Nearly 33% of the procedures were cancelled because of a mistake or issue related to the hospital, such as scheduling errors resulting in a lack of equipment or beds.

Study author Sabrina Bent, director of research at Tulane University’s Department of Anesthesia, says most of the costs incurred from cancelled procedures stem from “opportunity costs” as hospitals often are unable to move other procedures into the cancelled time slot.

Variation in the cost of cancellations
In addition, the study found that some surgeries cost more to cancel than others. Specifically, they found that:

  • Neurosurgeries cost $5,962 to cancel;
  • Urology procedures cost $4,758 to cancel;
  • Otolaryngology procedures cost $4,623 to cancel;
  • Thoracic surgeries cost $4,208 to cancel;
  • Ophthalmology procedures cost $2,927 to cancel;
  • Radiology procedures cost $2,787 to cancel;
  • Orthopedic procedures cost $2,779 to cancel;
  • Plastic surgeries cost $2,260 to cancel;
  • General surgery procedures cost $1,965 to cancel; and
  • Pediatrics procedures cost $1,325 to cancel.

How to prevent cancellations
To avoid cancellations, researchers recommend performing preoperative visits with all patients. In the study, only 4% of surgeries where patients had a preoperative clinic visit with an anesthesiologist were cancelled. In comparison, 11% of surgeries where patients did not have a preoperative visit were cancelled.

Researchers also suggest that hospitals focus on surgeries that result in the highest losses, such as neurosurgery and urology. While hospitals may be unable to solve all cancellations, “maybe there is something you can do to improve the efficiency and lack of cancellations in specialized groups,” Bent said (McCook, Anesthesiology News, 5/2012).


It’s all just numbers game they say, right?

Well, that’s not the end of the story.

In fact, we’re a long way from end. The pile-on and justification for Patient Cancellation Policies and add-on fee demarcation for price shocking a new, existing and yes, even former Patient or family continues.

CMT Graphic Ad (3) myconciergefitnessEach open, unused time slot costs a physician 60 minutes and $200 on average. Some estimates show missed appointments cost single physicians as much as $150,000 annually. A seasoned writer covering the healthcare industry, Shawn McKee, researched one clinic that had 14,000 no-shows in a single year with an estimated loss of over a million dollars. To calculate the financial cost of a no-show for your practice, take your average number of patients you typically see in a month, multiply that by your average no-show rate, and then multiply that number by your average cost of an appointment.[4]

So, who else is knocking at the door telling Doctors this is a good idea?

Then, who comes knocking? The thousands of Practice Management articles you’ve read, medical magazines, healthcare bloggers who get paid to write these articles and not to mention, practice management companies.

Not only do these articles, individuals and healthcare magazines which I’m sure you are well reading regularly encourage the use of Patient Cancellation Policies, they justify, support and encourage the strong enforcement of such practices inside a medical office.

Multiple practice management and medical news articles entitled Are you prepared with a solid cancellation policy?


Dr. Robert Nelson of Atlanta, GA – (470) 297-8089

“Until Doctors can be on time and get you in and out in a reasonably timely manner then I don’t think we have any justification for cancellation fees,” says Dr. Robert Nelson, a Direct Primary Care Doctor and Founder of Encompass Health Direct.

They may also say that a Physician should have … Clear verbiage stating the notice of cancellation (24 hours or 48 hours). For example, Clearly stated billed amount for missing an appointment (e.g. $25, $40, $50)

I understand in some practices, missed appointments are costly. That’s a valid point. Can every medical office do-away with Patient Cancellation fees? Nope. And I get that. The point is the amount of justification we all have for drawing the line in the sand with a Patient that when they see that fee on a piece of paper they know you care more about your fee than you do about their health.

Under many State laws enacted before the Privacy Rule, entities can charge individuals fees for copies of their medical records (usually the maximum fee is set by the law), but fees that are not cost-based may be contrary to the Privacy Rule.[8]

concierge medicine forum 2018 atlanta 3If you shudder like I do when we see these very clear lines of distinction between patient and provider, you probably get upset. Healthcare is already expensive, then we surprise people with add-on fees? When we see articles from practice management journals and consultants say things like Something to keep in mind when educating your patients on your cancellation policy, is to explain the reason why you have it. Patient care is why you are in the industry you are. You care about their health. Sometimes, more than they do. They are also aware that you have put them on notice, and will think twice about not showing up, or calling to cancel instead of going shopping or to lunch with a friend.

It’s almost as if a Patient starts to see their Doctor and his/her staff somewhere in the back-office saying … “Just try! I’ll get you, my pretty – and your little dog, too! Ah-hah-hah-hah-hah-hah!” a popular movie quote from Wizard of Oz.

It doesn’t stop there. The Centers for Medicare & Medicaid Services (CMS) has a policy on missed appointments as well.

The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare. According to Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge non – Medicare patients for missed appointments and the charges for Medicare and non- Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician’s or supplier’s missed appointment policy applies equally to all patients (Medicare and non- Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly. The other key points of CR5613 are: • The provider may bill the Medicare beneficiary directly. • Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers . • Claims for missed appointments sent to Medicare will be denied with the reason code 204 (This service/equipment/drug is not covered under the patient’s current benefit plan.). • In most instances , a hospital outpatient department can charge a beneficiary a missed appointment charge. • In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee.[5]

One Concierge Medicine Physician said “As a house call MD, I have never had a missed appointment I text before heading over.”

Now, As if that wasn’t enough. Why The Extra Charges On The Patient Bill For Immunization Record Copies and A One-Page Sports Physical Form Copy?

“Our profit margin in pediatrics is shrinking every day, which is why there are very few independent practices remaining. Physicians are beginning to think the only way to stay alive is to join a larger group or sell out to a hospital-based organization,” says Kressly, who launched her own practice after 15 years in a big group. In 2006, she hired another female pediatrician who became her business partner in January.[9]

How Fees in Concierge Medicine Programs for Sports Physicals and Vaccination Letters Are Handled …

How Fees in DPC for Sports Physicals and Vaccination Letters

Are Handled …

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[2] Missed appointments cost the U.S. healthcare system $150B each year; By Jamie Gier;

[3] Same-day surgery cancellations cost hospitals millions: Hospitals can prevent cancellations with preoperative patient visits, researchers say;







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