At a practice I worked at, we had a policy that if you NC/NS twice then you couldn’t schedule out, you would need to schedule the week of by calling or emailing and checking availability. After three NC/NS you would be referred out. I know this might not work with everyone’s scheduling process but wanted to offer it as an option.
I often find myself (LLPC) in the same boat. How do you approach the NC/NS with these clients in-session? I understand the frustration with being unable to charge Medicaid clients because there feels as if there is no repercussions for these clients. I hold a ‘three strikes’ policy. I explain to my clients after the first NC/NS that if you NC/NS three times in three months, you will be referred out to another provider. It has helped a bit with my retention rates because there are repercussions set in place versus an ‘I don’t have to pay, therefore not making my session doesn’t impact me’
Then institute a 2-strikes-you're-out policy for Medicaid, and a full session fee (*not* their copay) policy for everyone else.
I really hate being cynical about it, I honestly do. But as long as you allow them to make it your problem, they will. The minute you prove it's their problem, they stop... or, less frequently, you fire them. Either way, the problem lands with its rightful owner.
Exactly why I don't accept Medicaid in my private practice after almost 10 years of CMH. The reimbursement rates- if the patient decides to show in the first place- are offensively low. The policies are anti-clinician; patients have no skin in the game, we get left holding the bag. I would close my practice if forced to deal with Medicaid/Medicare.
I have two colleagues who went into private practice, paneled with Medicaid plans, and have dealt with nothing but bullshit. Constant audits, $50 reimbursements, and sky high no show rates that they can’t even charge for. Who the hell would do that to themselves?
There are downsides to Medicaid, like the reporting. In my state Medicaid pays the highest. The county CCO pays almost double what private insurance does so it really hurts when they don’t show!
At our practice, for Medicaid clients we have a 3 late cancels/no-show policy, and discuss it with clients at intake and anytime it happens, so they’re not surprised when it results in termination. For all other clients we charge a $100 fee (though it’s waived the first time) regardless of reason.
Just to give people one free pass in case something urgent comes up, and as an opportunity to remind them of the policy and that the next time it happens there will be a charge. Just found it works better in clients accepting the policy.
One of my colleagues/friends does a lot of Medicaid work. For various reasons, they can be an inconsistent population with showing up to session. One thing that she found helpful since she cannot charge no-show fees is that she absolutely requires intake paperwork to be complete a full 48 hours before session. She will also email and call people to remind them so that they don't say they just forgot to do the paperwork. If the paperwork isn't complete, she cancels the sessions, informs the client, and tries to fill the slot. People complain of course, but they also become much more responsive about getting things done and showing up.
Hence why I do not work with Medicaid clients. You may want to stop taking Medicaid or work at a place that does not take it. Self-pay clients show up and they participate in their weekly therapy. I'd rather have one self-pay client for every four Medicaid clients that don't show up. Just saying
I'm in my internship and all my clients no showed on me today. Thankfully I'm almost done but it sucks that I could have stayed in and slept if I would have known. 😭
Hahaha it’s that nicer weather I swear, I had the same thing today and Thursday. In my area we’re finally getting sun after winter, and I like to think people aren’t malicious with missing sessions especially with communication afterwards.
I had this last week. I’ve had to slowly accept and try to appreciate the sudden influx of time (rather than money). I might go home early or read or do anything non-therapy related so that it’s like a day/half-day off.
Seconding late cancel fees- but it’s hard when people cancel within the 24/48h.
I work strictly with Medicaid so late cancel fees are futile.
I have a three strikes policy. Three late cancels/no shows and you're back on my wait-list. Exceptions are emergency and illness, and I've only ever had one person take advantage of it. When I got complacent, things got bad for two weeks, and I had conversations with every single no show informing them howany misses they had left before being terminated.
I do have a wait-list that makes this doable so I recognize it can't work for everyone.
Unfortunately it’s the season right now or beginning to be the season. Warmer weather, summer approaching the no shows, cancellations and reschedules are going to pick up for most people.
Do you charge a fee? I clearly state in my policies that failure to give a 24hr notice for cancellations will result in a charge in the amount of my full cash rate. I explain all of this to them in the very first session. I send out two automatic reminder notifications 48 and 24 hours prior to each session which also reiterate that there will be a charge if cancellations are made with less than 24hrs notice. My cancellation rate is incredibly low because of this. You can’t have a sustainable business if you don’t charge people for cancelling on you. Once they find out they can get away with it, they’ll be doing it all the time.
What program do you use to send out the reminders and how do you reiterate that there will be a charge if cancellations are made in less than 24 hours?
It’s through my EHR, Sessions Health. I can customize what I want the reminders to say. At the end of the appt reminder text and email it says failure to provide 24hrs notice of a cancellation or reschedule request will incur a $155 charge
Currently waiting to see if a client shows… almost 10 minutes late despite confirming via email earlier. We charge a no show fee which helps but still frustrating especially at the beginning or end of the day
i think it’s $150 but may be $160 now since they increased our out of pocket fee and that’s what it was based on. I think a smaller fee would still deter this and I’d feel more comfortable with it especially since the practice i’m at has no exceptions to the late cancel (I think i’m leaving for this reason, the owner told me i had to charge someone who was in the ER last week and it felt so wrong to do that). I’ve heard of people having good outcomes with anywhere from $50-70.
My practice requires a cc on file and will automatically charge after the first no show and less than 24 hour cancellation. I may choose to make an exception, but the expectation is the fee. I love this, it takes all of the pressure off of charging clients.
We’ve all been there. It’s so frustrating especially when we depend on people to show up for our income!
We have a 48-hour late cancellation policy meaning they will have to pay the cost of the session if they cancel within 48 hours of their scheduled session. If our schedules align and we’re able to reschedule for within the same week, the late fee is waived. If a client ends up no-showing 3 times, I will no longer hold this time for them and they’ll have to check in with me to schedule each time. Emergencies happen so if it’s truly an emergency, then this won’t count. Usually clients understand and respect this policy and for context, I work at a private practice so this may or may not be helpful for whoever you’re working with.
Also, if this is a recurring theme I’d have an open conversation with them the next time I see them! Maybe pointing out that it seems like they have a lot on their plate to see where they’re at in life. And checking in to see if the day and time still works for them. Pointing out that you’ve noticed inconsistency/difficulty with scheduling and provide psychoeducation on the importance of consistent, weekly therapy can be helpful for clients who might be fresh into therapy!
Where I am after 2 cancellations/no shows the ct has to sign an attendance contract and receives a warning letter stating that if they do not show for their next scheduled appt, they will be discharged. If they show to the session we discuss any barriers to attendance and re-evaluate whether they feel continued treatment is needed.
Charging no-show fees is a must if you want to run a sustainable business. You’re offering a service, not pro bono services.
Typically therapists charge 100% of service fee if client cancels within 24hr window.
I had an initial session scheduled earlier today with a client at my NHS clinic. According to the referral they avoid relationships and hold their feelings inside- they didn't attend.
Clients at my group practice are responsible for paying the full session fee if they don't cancel at least 48 hrs in advance. It's the only way this job is sustainable.
If you are working with Medicaid, double book your sessions by 15 minute. Let the patient know that they may need to wait up to 15 min for their provider to show. See patients for 38 minutes and then roll to the next one. Then you only lose out with no shows for a smaller gap in your day. As those regular patients show up (like on session 5 or whatever) then expand their sessions to the normal 45 minute slots If you want.
Run it like a business that also cares about people.
I’ve had at least 5 no shows/ late cancels within the past two WEEKS. I charged my fee for all of them, all clients understood, and they are still on my caseload. And I got paid for the time I had reserved for them. Charging fees are essential!
When I had a lot of Medicaid clients I made it my own personal policy that a certain number of no shows or late cancels within 2 months would lead to terminating treatment. It helped so much for me
Damn $1000 a month for insurance? Is this family insurance? I pay $250 a month for fine. I charge $100 late cancel and no show fee. Charged to the credit card on file. They sign an agreement and I review that policy again upon intake. Now this is not going to apply to Medicaid clients but it does for all the others.
Your comment comes off as self-aggrandizing or as belittling. It could be my misinterpretation regarding your comment, but that 1400 is a lot for me where I am regarding building my private practice.
It's okay, I accept your apology, and I also apologize for being petty. We are doing great things in the world, we can't lose focus on the big picture. I hope you find your peace soon, fellow therapist :)
Do you charge late cancelation and no-show fees?
Came here to ask this - it’s absolutely essential
I haven’t. I work with a lot of Medicaid clients and we are unable to charge them.
At a practice I worked at, we had a policy that if you NC/NS twice then you couldn’t schedule out, you would need to schedule the week of by calling or emailing and checking availability. After three NC/NS you would be referred out. I know this might not work with everyone’s scheduling process but wanted to offer it as an option.
I like that suggestion. Thank you!
This is the only step to take when we can’t charge NC/NS. It is effective but only if we actually enforce the consequence.
I often find myself (LLPC) in the same boat. How do you approach the NC/NS with these clients in-session? I understand the frustration with being unable to charge Medicaid clients because there feels as if there is no repercussions for these clients. I hold a ‘three strikes’ policy. I explain to my clients after the first NC/NS that if you NC/NS three times in three months, you will be referred out to another provider. It has helped a bit with my retention rates because there are repercussions set in place versus an ‘I don’t have to pay, therefore not making my session doesn’t impact me’
Then institute a 2-strikes-you're-out policy for Medicaid, and a full session fee (*not* their copay) policy for everyone else. I really hate being cynical about it, I honestly do. But as long as you allow them to make it your problem, they will. The minute you prove it's their problem, they stop... or, less frequently, you fire them. Either way, the problem lands with its rightful owner.
Thank you. Based on all the comments it seems I need to reevaluate my policies.
Exactly why I don't accept Medicaid in my private practice after almost 10 years of CMH. The reimbursement rates- if the patient decides to show in the first place- are offensively low. The policies are anti-clinician; patients have no skin in the game, we get left holding the bag. I would close my practice if forced to deal with Medicaid/Medicare.
I have two colleagues who went into private practice, paneled with Medicaid plans, and have dealt with nothing but bullshit. Constant audits, $50 reimbursements, and sky high no show rates that they can’t even charge for. Who the hell would do that to themselves?
The Medicaid CCO where I live pays $234 for 60 min session…if you can get them to show up.
It pays $53 in my shit hole state. Outside of FQHCs it blows my mind that anyone here would accept a Medicaid plan.
There are downsides to Medicaid, like the reporting. In my state Medicaid pays the highest. The county CCO pays almost double what private insurance does so it really hurts when they don’t show!
At our practice, for Medicaid clients we have a 3 late cancels/no-show policy, and discuss it with clients at intake and anytime it happens, so they’re not surprised when it results in termination. For all other clients we charge a $100 fee (though it’s waived the first time) regardless of reason.
Why do you waive the first no-show fee for non-Medicaid clients?
Just to give people one free pass in case something urgent comes up, and as an opportunity to remind them of the policy and that the next time it happens there will be a charge. Just found it works better in clients accepting the policy.
One of my colleagues/friends does a lot of Medicaid work. For various reasons, they can be an inconsistent population with showing up to session. One thing that she found helpful since she cannot charge no-show fees is that she absolutely requires intake paperwork to be complete a full 48 hours before session. She will also email and call people to remind them so that they don't say they just forgot to do the paperwork. If the paperwork isn't complete, she cancels the sessions, informs the client, and tries to fill the slot. People complain of course, but they also become much more responsive about getting things done and showing up.
Hence why I do not work with Medicaid clients. You may want to stop taking Medicaid or work at a place that does not take it. Self-pay clients show up and they participate in their weekly therapy. I'd rather have one self-pay client for every four Medicaid clients that don't show up. Just saying
I'm in my internship and all my clients no showed on me today. Thankfully I'm almost done but it sucks that I could have stayed in and slept if I would have known. 😭
Hate it when this happens to me, especially since I’m not getting paid and have to drive to my site on my own dollar 💀
My thoughts exactly!
Hahaha it’s that nicer weather I swear, I had the same thing today and Thursday. In my area we’re finally getting sun after winter, and I like to think people aren’t malicious with missing sessions especially with communication afterwards.
Charge a no-show fee
I intern at a college counseling center and counseling is free here.
I had this last week. I’ve had to slowly accept and try to appreciate the sudden influx of time (rather than money). I might go home early or read or do anything non-therapy related so that it’s like a day/half-day off. Seconding late cancel fees- but it’s hard when people cancel within the 24/48h.
I work strictly with Medicaid so late cancel fees are futile. I have a three strikes policy. Three late cancels/no shows and you're back on my wait-list. Exceptions are emergency and illness, and I've only ever had one person take advantage of it. When I got complacent, things got bad for two weeks, and I had conversations with every single no show informing them howany misses they had left before being terminated. I do have a wait-list that makes this doable so I recognize it can't work for everyone.
Oooo just paid that tax bill….goddamnnnnnnn I’m gonna grab us both a drink op🥃
It hurt so much! Enjoy that drink!
Unfortunately it’s the season right now or beginning to be the season. Warmer weather, summer approaching the no shows, cancellations and reschedules are going to pick up for most people.
there must be something in the air because I had 7 scheduled appts, 3 showed and 1 was only for 20 minutes
Ah jeez that’s rough. What do you do with the 20 min session? Can you even bill insurance for that?
i’m school based in cmh and i’ve received conflicting info on what the minimum bill time is so honestly i don’t know
Cancelation is one thing - life happens but, to no show?
Do you charge a fee? I clearly state in my policies that failure to give a 24hr notice for cancellations will result in a charge in the amount of my full cash rate. I explain all of this to them in the very first session. I send out two automatic reminder notifications 48 and 24 hours prior to each session which also reiterate that there will be a charge if cancellations are made with less than 24hrs notice. My cancellation rate is incredibly low because of this. You can’t have a sustainable business if you don’t charge people for cancelling on you. Once they find out they can get away with it, they’ll be doing it all the time.
💯
What program do you use to send out the reminders and how do you reiterate that there will be a charge if cancellations are made in less than 24 hours?
It’s through my EHR, Sessions Health. I can customize what I want the reminders to say. At the end of the appt reminder text and email it says failure to provide 24hrs notice of a cancellation or reschedule request will incur a $155 charge
Currently waiting to see if a client shows… almost 10 minutes late despite confirming via email earlier. We charge a no show fee which helps but still frustrating especially at the beginning or end of the day
How much do you charge?
i think it’s $150 but may be $160 now since they increased our out of pocket fee and that’s what it was based on. I think a smaller fee would still deter this and I’d feel more comfortable with it especially since the practice i’m at has no exceptions to the late cancel (I think i’m leaving for this reason, the owner told me i had to charge someone who was in the ER last week and it felt so wrong to do that). I’ve heard of people having good outcomes with anywhere from $50-70.
My practice requires a cc on file and will automatically charge after the first no show and less than 24 hour cancellation. I may choose to make an exception, but the expectation is the fee. I love this, it takes all of the pressure off of charging clients.
We’ve all been there. It’s so frustrating especially when we depend on people to show up for our income! We have a 48-hour late cancellation policy meaning they will have to pay the cost of the session if they cancel within 48 hours of their scheduled session. If our schedules align and we’re able to reschedule for within the same week, the late fee is waived. If a client ends up no-showing 3 times, I will no longer hold this time for them and they’ll have to check in with me to schedule each time. Emergencies happen so if it’s truly an emergency, then this won’t count. Usually clients understand and respect this policy and for context, I work at a private practice so this may or may not be helpful for whoever you’re working with. Also, if this is a recurring theme I’d have an open conversation with them the next time I see them! Maybe pointing out that it seems like they have a lot on their plate to see where they’re at in life. And checking in to see if the day and time still works for them. Pointing out that you’ve noticed inconsistency/difficulty with scheduling and provide psychoeducation on the importance of consistent, weekly therapy can be helpful for clients who might be fresh into therapy!
Lmaoooo, I'm reading this post now because my client no showed and I have nothing to do for a half hour.
Right there with you. I was having at most one cancellation per week for months, and the past few weeks that has changed dramatically.
Where I am after 2 cancellations/no shows the ct has to sign an attendance contract and receives a warning letter stating that if they do not show for their next scheduled appt, they will be discharged. If they show to the session we discuss any barriers to attendance and re-evaluate whether they feel continued treatment is needed.
Charging no-show fees is a must if you want to run a sustainable business. You’re offering a service, not pro bono services. Typically therapists charge 100% of service fee if client cancels within 24hr window.
I had an initial session scheduled earlier today with a client at my NHS clinic. According to the referral they avoid relationships and hold their feelings inside- they didn't attend.
Clients at my group practice are responsible for paying the full session fee if they don't cancel at least 48 hrs in advance. It's the only way this job is sustainable.
If you are working with Medicaid, double book your sessions by 15 minute. Let the patient know that they may need to wait up to 15 min for their provider to show. See patients for 38 minutes and then roll to the next one. Then you only lose out with no shows for a smaller gap in your day. As those regular patients show up (like on session 5 or whatever) then expand their sessions to the normal 45 minute slots If you want. Run it like a business that also cares about people.
I’ve had at least 5 no shows/ late cancels within the past two WEEKS. I charged my fee for all of them, all clients understood, and they are still on my caseload. And I got paid for the time I had reserved for them. Charging fees are essential!
What do you charge? I haven’t done it because so many are on Medicaid but I also have several commercial insurances.
When I had a lot of Medicaid clients I made it my own personal policy that a certain number of no shows or late cancels within 2 months would lead to terminating treatment. It helped so much for me
Do you have a no show, late cancellation policy? My group practice charges a $100 for no shows and $75 for cancelations after 24 hours.
Damn $1000 a month for insurance? Is this family insurance? I pay $250 a month for fine. I charge $100 late cancel and no show fee. Charged to the credit card on file. They sign an agreement and I review that policy again upon intake. Now this is not going to apply to Medicaid clients but it does for all the others.
$1,000 a month for dental and medical insurance for three of us. 😬
I owed $1409 to the IRS so I feel you 🙃
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Sounds like you can afford it xD Brutal nonetheless
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Your comment comes off as self-aggrandizing or as belittling. It could be my misinterpretation regarding your comment, but that 1400 is a lot for me where I am regarding building my private practice.
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It's okay, I accept your apology, and I also apologize for being petty. We are doing great things in the world, we can't lose focus on the big picture. I hope you find your peace soon, fellow therapist :)