“I’m late, I’m late! For a very important date! No time to say ‘hello, goodbye,’ I’m late, I’m late, I’m late!” —The White Rabbit in Alice in Wonderland
Let’s begin with the good news and the bad news. The bad news is that due to budget neutrality changes required by law, the proposed 2024 conversion factor is $32.75, a decrease of $1.14—or 3.34% from the 2023 conversion factor of $33.89.(1) The conversion factor, which is used to determine the fee-for-service Medicare payment, is the multiplier that Medicare applies to relative value units (RVUs) to calculate reimbursement for a particular service or procedure under Medicare’s fee-for-service system. After adjusting for inflation in practice costs, Medicare physician payments between 2001 and 2021 declined 22%.(2)
The good news is that practices that start to focus on improving efficiency can more than make up for the decrease in the conversion factor by seeing more patients while preserving patient satisfaction and the practice’s online reputation.
Use of Technology
Virtual Visits
Patients, especially millennials, are looking for access and convenience, which makes telemedicine attractive. The use of telemedicine, once a seldom-used technology, has, since the COVID-19 pandemic, increased significantly, especially since there is financial parity between a face-to-face visit and a virtual visit.
Telemedicine visits can be very productive for both patients and doctors. For the most part, the visit should be the same as a face-to-face visit even if the doctor is unable to physically examine or touch the patient. Telemedicine is going to be the “new normal,” and many patients are going to request this method of communication today and tomorrow.
Prior Authorization
Obtaining prior authorizations, coding claims, and chasing denials take up valuable time and can negatively impact care. The average physician spends 14 hours a week of uncompensated time obtaining prior authorizations. There are now revenue cycle management programs that take on the prior authorization process so the doctor and other staff can focus on caring for patients. These programs include medical coding and claims resolution services as well, which can significantly help practices work more efficiently. These automated programs relieve the staff of work, including researching requirements, tracking changes, calling payers for authorizations, and other administrative billing tasks.
Remote Patient Monitoring
Remote patient monitoring, also referred to as remote physiologic monitoring, is the use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations, adjustments in medications or treatments, and instructions. The Center for Connected Health Policy states that remote patient monitoring programs keep patients healthy and allow older and disabled individuals to live at home longer, avoid having to move into skilled nursing facilities, and cut down on visits to emergency departments.(3) Remote patient monitoring also can serve to reduce the number of hospitalizations, readmissions, and lengths of stay in hospital—all of which help improve quality of life and potentially contain costs and improve the efficiency of the practice.
Automated Online Patient Appointments
Practices are expected to provide easy and convenient facilities, as well as high-quality care. Online scheduling programs enable patients to book or request appointments and can bring many benefits to practices that use them.
With online scheduling, staff can better spend their time providing a positive experience for patients who are physically in the office.
Existing and potential patients are less inclined to make phone calls to make an appointment than in the past. Instead, patients prefer using a website or an app to book an appointment. New patients looking for a new doctor are more attracted to those practices who offer online scheduling. Online scheduling enables patients to make same-day or next-day appointments. This can be accomplished by the patient 24/7, no matter whether it is late in the evening, on a weekend, or early in the morning when the practice is closed. They can quickly check a practice’s availability and create an appointment that suits their schedule.
Another advantage of online scheduling is the ability for a practice to fill empty appointment slots.
Finally, your front office staff will appreciate online scheduling. The relief from administrative tasks such as multitasking and answering phone calls will allow the staff to focus on patient care. With online scheduling, staff can better spend their time providing a positive experience for patients who are physically in the office.
Preparing Patients for Their Encounter
Typically, patients arrive in the office and are asked to complete paperwork, which can take 20 to 30 minutes. Efficient practices have patients complete their demographic and insurance information online and submit the paperwork to the office, where it is then scanned into the patients’ EMR. We also recommend that the health questionnaire include the past medical history and review of systems and that this also is completed before the patient comes to the office. Now when a patient arrives in the office, they can be taken to the exam room instead of waiting in the reception area to complete the time-consuming paperwork. This avoids delays and improves the efficiency of the practice’s schedule.
Staff Motivation
To have a smoothly running staff, it is necessary to have well-developed policies and procedures. This is best accomplished with a clearly written and concise policy manual. A policy manual tells employees what is required of them and how to abide by the rules of the practice. Every job and position in the practice also should have access to a procedure manual. A procedure manual helps train new employees and helps current employees know how to do their jobs. If your new receptionist has a procedure manual to follow, they will know what to do and what not to do, and will become competent in that position much faster if they have a written handbook to follow. An employee handbook should include the following information:
Practice history, vision, mission statement and core values;
Code of conduct and policies;
Working hours;
Dress code;
Privacy and security information;
Benefits for full-time and part-time employees;
Paid time off policies (sick time, vacation time, bereavement);
Resignation and termination processes;
Anti-harassment policies and processes; and
Acknowledgment of receipt.
An employee manual or procedure manual gives employees a detailed overview of policies that are specific to your practice along with other key procedures and guidelines and also lays out employee benefits. The manual sets clear expectations for your employees while also stating your legal obligations and defining employee rights. The employee manual can help protect your practice against employee lawsuits and claims, such as wrongful termination, harassment, and discrimination. Whenever possible, break down processes into component parts, such as scheduling, rooming the patient, office procedures, and making follow-up appointments.
It is helpful to use technology to enhance your efficiency. For example, you may need prior authorization before treating a patient or before ordering an imaging study. Obtaining prior authorization can take a staff member as long as 30 to 60 minutes. This also can slow down the physician if they must wait on the phone to obtain prior authorization. This process can be performed using prior authorization software or even delegating the process to an employee who has skills and training to obtain these permissions.
Scheduling Recommendations
The schedule often is the greatest logjam in the efficiency of a medical office. When physicians are asked how many patients they typically see when they have a full schedule, they will offer a variety of responses. Some doctors consider their practice to be fully booked when they see 15 patients a day, whereas other, more efficient, physicians are comfortable and not stressed when they see 30, 40, or even 50 patients a day.
Most physicians have no idea of the maximum number of patients that they can see on any day. The usual situation is that each physician’s maximum capacity is determined by their scheduling programs. Every practice eventually reaches a point of equilibrium at which the volume of patients seen levels off and growth of the practice is brought to a halt. The equilibrium point is different for each practice, but the equilibrium point often is reached because a predetermined number of slots in the appointment book have been filled in. The available number of slots often has been determined arbitrarily by the software company or has been based on the volume of other, similar practices. This number of slots has nothing to do with the doctor’s available office space or the number of exam rooms or that doctor’s and staff’s abilities to see more patients. For example, if the computer software program suggests that the time for each slot be reduced from 30 minutes for each patient to 15 minutes, the volume of patients seen will immediately double, and there will be a concomitant increase in productivity. With further review, it is determined that some patients can be seen effectively in less than 10 minutes, which further increases the volume of patients that can be seen.
Regardless of the scheduling program you are currently using, if you want your practice to grow, consider adding more slots than the number of patients you are currently seeing on your busiest day. When your practice finds that the busiest day becomes your average day, then it is time to consider adding a new partner or a mid-level provider such as a physician assistant or nurse practitioner. Another indicator that you have maxed out your schedule is the situation where patients must wait more than four weeks for a new or routine appointment.
Not every patient requires a 15-minute appointment.
Medical practices often resort to overbooking to counteract the effect of no-shows. This is a method that I don’t recommend. I know that many practices experience large numbers of no-shows, which results in holes in the schedule that make the schedule look like Swiss cheese. I agree that no-shows waste staff time, upset existing patients, and ultimately lead to physician and staff burnout and even decreased productivity. There are multiple methods of reducing the no-show rate. For example, some software programs can automatically call patients to remind them of their appointments and ask them to confirm the appointment. If the patient says they will not be able to keep the appointment, the program then contacts patients who are on a waiting list or new patients who are asking for appointments sooner than the appointment that has been previously scheduled for them.
Not every patient requires a 15-minute appointment. Checking blood pressure and reviewing medications does not take 15 minutes. A patient with a urinary tract infection who is asymptomatic, and whose urinalysis is negative also does not need a 15-minute appointment. A patient with a recent diagnosis of cancer may require 30 minutes or more and is best scheduled at the end of the day, leaving the appointment open-ended so that patients with appointments earlier in the day will not be delayed because you spent a longer time with the cancer patient. I suggest that you consider allocating appropriate time slots for injections, procedures, follow-ups, and new patients or consults.
One of the best methods to enhance efficiency is effective scheduling. Every practice has several urgencies or emergencies every day that must be worked into the schedule, and these few additional patients can wreak havoc with the schedule. I suggest you leave at least two open time slots available—one in the late morning and one mid-afternoon—that can only be filled after the practice opens. These slots are reserved for urgencies, emergencies, and new patients.(4)
No-Shows Means No Dough
Every practice is concerned about decreasing reimbursements and increasing overhead costs, which translates to an erosion of the bottom line. Although there is little we can do to increase reimbursements, there is a lot we can do to improve the efficiency and productivity of our practices. One of the simplest methods is to decrease the no-show rate, a problem that affects most medical practices.
Each missed appointment costs the practice approximately $140—and that’s a conservative estimate based only on the office visit. That amount quadruples—or more—if that missed appointment represents a surgery. If you have multiple no-shows each day, you don’t need an MBA to calculate the lost income that can impact your practice and your practice productivity.
Prevention of No-Shows
It is time for a cultural shift regarding scheduling. Instead of focusing on barriers to access—including celebrating when the patient doesn’t keep an appointment (said tongue in cheek, but often a reality), physicians must motivate staff to keep the doctor’s schedule completely full. The staff must understand that open time slots are a loss of income to the practice, and a full, robust schedule improves productivity and profitability. When the latter occurs, the physician should compliment the entire team and say, “Thank you for giving me a full day.”
Calling patients several days before their appointments is very time consuming for your staff. This is an opportunity to use technology by implementing automated appointment reminders. Automated appointment reminders improve patient engagement, keep your schedule full, and reduce the no-show rate. It is of interest that most patients prefer to receive appointment reminders via text message. Twice as many people preferred secure texting with their providers compared with receiving communications via a patient portal.(5)
No-shows can be prevented. Begin by requesting three phone numbers for each patient. This includes home number, work number, and cell phone number. If three is too many, ask for the “best” number. Automated systems for contacting patients are available, but these are not as effective as a human being contacting a patient. Increasingly, practices are reminding patients through an automated, text-based service.
Studies have demonstrated that a longer time interval between appointments significantly increases the no-show rate. For example, patients who are given an appointment more than 150 days after their last appointment may have a significantly higher no-show rate—as much as 30%, whereas patients who have an appointment within 10 days of their last office visit have been found to have a no-show rate below 5%, according to one study.(6) Identify those patients who are likely to miss their appointments with a “warm” confirmation. Examples include patients who have been given an appointment more than 150 days after their most recent preceding appointment; patients who previously have canceled appointments; patients who are scheduled for a procedure; new patients; or patients from certain demographics or payer types who have a history of not keeping their appointments.(7)
Another option for reducing the no-show rate is to consider accepting electronic appointment requests. Many practice management systems include programs that allow patients to request an appointment, after which you contact them to confirm a date and a time.
You want to make it easy for patients to cancel an appointment. If a patient cancels an appointment, be sure to follow up and give the patient the opportunity to reschedule. Also, let the patient know that you appreciate the notification about the cancellation.
Another effective method of reducing the no-show rate and keeping the schedule full is to maintain a waiting list of patients who would like an earlier appointment than the one they currently have. Consequently, when openings occur, the scheduler or receptionist can go to the waiting list and contact patients who could potentially fill those open slots.
Of course, it is necessary to carefully document all no-shows in the patient’s chart or EMR. No-shows are a significant liability for the practice, and consulting with your malpractice carrier about the protocols is recommended.
Charging for No-Shows
There are advantages and disadvantages to charging a penalty for no-show patients. Perhaps charging the patient provides the patient an opportunity to change their behavior. We think it is a good idea to let the patients know that the doctor was expecting them, held a time slot for them, and that their last-minute cancellation or failure to keep the appointment kept another patient who needed the doctor’s services from being able to use that appointment time. I suggest charging patients who are second-time offenders. Patients should receive a warning for a first-time offense. Reasons not to charge patients include difficulty collecting the no-show fee as well as being a source of negative public relations for your practice. Another suggestion for the repeat offender is to require prepayment to “hold” the slot. The receptionist informs the patient that the appointment will be held for them but that a credit card number is required to hold the appointment. If the patient is a no-show, you submit a fee using their credit card.
CMS Guidelines to Charging Medicare Patients for No-Shows
As of 2007, CMS policy allows physicians to charge Medicare patients for missed appointments if the practice does not discriminate and does not charge only Medicare patients such a fee. The practice must be consistent and charge for non-Medicare patients who miss appointments as well. The guidelines also stipulate that the charges for missed appointments for both Medicare and non-Medicare patients be the same.(8)
It does not require rocket science to reduce the no-show rate: attention to detail, looking at no-show patterns, and motivating staff to keep the schedule full are simple solutions.
On occasion we have had patients who are chronic no-showers but whom we did not want to remove from our practice. For example, if the patient needs a relative or friend to bring them to the appointment, so that their ability to be on time is out of their control, we suggest giving them the last appointment of the day. That way if they miss the appointment or arrive late, they won’t cause havoc with your schedule.
It does not require rocket science to reduce the no-show rate: attention to detail, looking at no-show patterns, and motivating staff to keep the schedule full are simple solutions.
Bottom Line: The COVID-19 pandemic changed the delivery of healthcare. At the top of the list of pain points is having a full schedule and being able to see patients on time. There is very little we can do to change healthcare reform. However, there is something we all can do to provide every patient with a positive healthcare experience—and that is to see the patient in a timely fashion.
References
Calendar Year (CY) 2024 Medicare Physician Fee Schedule Proposed Rule. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule
O’Reilly KB. Medicare physician pay cuts underscore need to fix broken system. AMA. December 20, 2022. https://www.ama-assn.org/practice-management/medicare-medicaid/medicare-physician- pay-cuts-underscore-need-fix-broken-system
Malasinghe LP, Ramzan N, Dahal K. Remote patient monitoring: a comprehensive study. Journal of Ambient Intelligence and Humanized Computing. 2019;10(1):57-76.
Baum N. Effective scheduling using sacred time. J Med Pract Manage. 2016;31:392-393.
Lin CT, Wittevrongel L, Moore L, Beaty BL, Ross SE. An Internet-based patient-provider communication system: randomized controlled trial. J Med Internet Res. 2005;7(4), e409.
Kheirkhah P, Feng Q, Travis LM, Tavakoli-Tabasi S, Sharafkhaneh A. Prevalence, predictors and economic consequences of no-shows. BMC Health Serv Res. 2016;16:13. https://doi.org/10.1186/s12913-015-1243-z
Samuels RC, Ward VL, Melvin P, et al. (2015). Missed appointments: factors contributing to high no-show rates in an urban pediatrics primary care clinic. Clin Pediatr. 2015;54:976-982.
Charges for missed appointments. MLN Matters. 2007; updated November 12, 2014. cms.hhs.gov/MLNMattersArticles/downloads/MM5613.pdf