Reducing No-shows to Generate Additional Counseling Revenue
Published in Caring, vol. XV, no. 1 (Spring 1999), p. 12-13

Almost all Alliance members offer counseling programs and all of these programs experience counselor down time or lost revenue when consumers fail to appear for appointments, or when consumers cancel at the last minute. The rate of no-shows runs from 10 percent to higher than 30 percent. Thirty percent seems to be the industry average. Most counseling managers report a much higher rate of no shows for intake sessions than for ongoing cases.

Our no-show rates fun in the neighborhood of 20-30 percent.
- John Jordon, clinical director, United Family Services, Charlotte, NC

Protecting Your Revenue Base
The first approach to protecting your revenue base is to charge for missed appointments. This strategy has been put into effect by many member organizations. Charging for misses will not be possible if the appointment is a service provided by Medicare or Medicaid, and in some cases if provided by a Managed Care Organization. However, even for Title XIX covered services, a small co-payment can be charged. Experience on third party reimbursement for failed appointments varies.

Many counseling centers also charge for appointments that are cancelled less than 24 hours in advance. In one particular case with which I am familiar, the agency charges full rate for missed appointments, and the balance due must be paid by the beginning of the next counseling appointment. This works reasonably well — meaning collections are high — for ongoing cases. Others report that collections are very poor for missed intakes.

However, many programs do not charge for missed appointments, and this amounts to missed revenue. Counselors do not have immediately available other revenue generating activities. Even if they engage in record keeping or writing up case notes, this time is not chargeable. If the clinicians are part-time or full-time staff rather than contracted, they sit idle on the company clock. In this case, you are not just missing the opportunity for revenue; you are actually losing money with each passing minute.

Generating Revenue from Down Time
Down time from missed appointments can be converted into revenue generating activity if the time is redirected, by using it to minimize no-shows. This stems from the recognition that any activity that reduces the frequency of no-shows is, in fact, a revenue-generating act. There are a variety of strategies for doing so.

Counselors can be directed to use missed appointment time to make reminder calls and to send out reminder cards for upcoming appointments. It works best when reminders reach the consumers one to three days ahead of their appointments. Since some consumers do not want their families to know about their contact with you, you must be careful to set the stage for reminder calls by informing them of this practice at the time of your first contact.

Counselors are not limited to reminding their own clients, but can just as well reach out to people being served by their colleagues at your organization. Of course, support staff can also make reminder calls, though this takes time from other support activities and therefore has direct costs. Finally, the business cards of your professional counselors should be formatted so that the reverse side functions as an appointment card.

The beauty of this approach is that any degree of success is money in your pocket. If even one no-show is avoided by one reminder call from a counselor, made during down time, it converts what would have been two hours of down time into one hour of potentially billable revenue. If counseling is billed at $90 per hour, this means that one effective reminder call during down time is worth $45. And how else can your counselors, even contracted counselors, generate $45 of revenue with a single phone call?

Clinical Issues in Reminder Calls
Some clinicians believe that reminding consumers of their obligations generates dependency. Before you accept this as a fatal flaw, consider several arguments in favor of reminding consumers.

First and foremost, your consumers cannot derive benefit from whatever supportive services you offer if they fail to have contact with your professional staff. The salutary effects of your counseling services should, easily outweigh whatever negative value is generated by the purported increased dependency.

The mental health profession needs to look at marketing tools and be flexible and creative in getting mental health services to people.
- Liz Bohne, clinical director, Family Service Aurora, Minneapolis

Next, it is worth considering whether facilitative techniques such as reminder calls are any different in intent and impact from other strategies by which counseling programs attempt to make services accessible and easy to use. Other strategies include locating services close to the consumers who use them, scheduling clinic hours which are convenient for them, applying means-tested sliding scales for fees, applying for reimbursement from third parties on behalf of the consumer, providing transportation, providing child care, home visits to provide counseling, or even just giving out appointment cards for the next appointment as the consumer leaves. The point of all such tactics is to help to deliver treatment.

Developing Management Information from Down Time
A variant of investing counselor downtime in reminder calls is to have the counselors perform research or follow up for you on recent no-shows. Here, they call consumers who failed to appear this week and survey them as to the reason for their missed appointment. Alternatively, they can analyze previously collected no show data. This information should feed back into your scheduling, arming you with knowledge about what types of appointments are most likely to be missed. Such knowledge permits you either to target your reminder efforts, or to change scheduling.

For example, most organizations report that the rate of no shows is higher for intakes than for ongoing cases. If that were true, you would want to concentrate your tactics on intakes. Make more intensive efforts to form a bond with the potential client during the initial contact, and then concentrate reminder calls on upcoming intakes. A caveat: several counseling managers have found a proportional relationship between the time spent on the phone at first contact and the likelihood of subsequent no-show at the intake appointment. In other words, the longer the call, the more likely the consumer is to miss their intake appointment. [Intriguing, no?] Others have found a relationship between waiting time for the appointment in days, and consumer response. Both very short turn around times (one to three days) and longer waits (10 to 14 days) were associated with poorer attendance. Waiting periods of four to seven days were associated with the best attendance. What is clear from this is that first, you must keep statistics on appointments, and second, you must allow them to guide you to an appropriate response.

An Innovating Response: Overbooking
You can also experiment with overbooking, a practice that is followed at many private mental health clinics, and is well known in medicine. Some Alliance members have begun to experiment with it. To engage in overbooking, you first need a detailed understanding of your no show statistics. Identify the range in the proportion of no shows during equal segments of the period, such as weeks (e.g., "no shows ranged from 15-50 percent of intake appointments during a given week"). Cluster your intake appointments during periods of the day or week when you can arrange to have a pool of clinicians on site. One colleague implements this strategy by scheduling appointments on the half-hour rather than the hour during the target period. Take note that overbooking rests on the premise of the interchangeability of counselors — a premise that will not always be met.

In my agency, when overbooking is discussed, it always seems to get shot down over 1) the matter of ethics of offering appointments which may not be able to be honored, and 2) the sense that we would be operating more like a public clinic, which is deemed to be undesirable.
- Kathleen Buescher, CEO, Provident Counseling, St. Louis

You will also need to make provision for those who show up and can't be served. Options include offering a free intake or counseling session at a later date, having a backup counselor available whose time is flexible, a qualified and supervised intern, or arranging coverage through a nearby collaborator. There is a significant risk of customer dissatisfaction if a person is turned away, and you must be prepared to address this outcome. Overbooking along these lines can be used not just for intake cases, but for any identifiable group of cases which can be clustered and which experience a significant proportion of no shows.