Introduction

A missed appointment is a business expense for a clinician for the following reasons:

1. The clinician could have filled the appointment slot.
2. There is a cost to the making of and canceling of appointments.
3. Even if the patient doesn’t show, the clinician still needs to review the patient’s chart, to ascertain whether there was an urgent need for followup with the patient. This is work that is not reimbursed.

Charging for Missed Appointments

The American Medical Association has opined that it is ethical for physicians to charge for missed appointments, or for appointments not canceled at least 24 hours in advance, if patients are fully advised of the possibility of such charges.

Practices should develop policies regarding missed appointments, and share the written policy with new and established patients, at reasonable intervals. Communicating the policy could be part of an intake process for new patients. Established patients could be notified of the policy when checking in for appointments, or when a patient is given an appointment, the receptionist could communicate the policy orally with followup by mail. If the practice has a Web site, the policy should be published there. The policy could be posted at the desk or in the waiting room. Send a copy of the policy along with the bill, when charging the patient for the no-show. The practice may want to ask the patient to sign the statement, acknowledging the policy and accepting responsibility for a charge for a missed appointment.

The missed appointment policy should not be used to deny care to a patient who presents for a scheduled appointment. That is, if a patient missed an appointment August 1, 2009, was billed for the missed appointment, has not paid, and shows up for an appointment on September 8, 2009, do not deny care on September 8 based on failure to pay the missed appointment charge.

Crafting a reasonable charge is tricky. Consider whether the practice is charging for actual costs or for the missed opportunity to charge. If the practice filled the appointment slot at the last minute, there is no missed opportunity. A brief Internet search revealed that practices charge $20 to $50 for missed appointments.

Specifics of the Policy

Typically, no-show policies apply to a patient who does not show or cancels less than 24 hours prior to the appointment. Practices may want to write a policy to apply to patients who are more than 15 minutes late for an appointment (after 15 minutes, the patient has missed the appointment). However, if the practice or clinician chronically runs late, there could be a significant public relations downside to implementing a 15-minute policy.

Here are some suggestions regarding policies:

• Consider letting the first missed appointment go without charge. If so, make it clear in the policy that the practice “understands events can occur unexpectedly and therefore, a one-time missed appointment will not be charged.”
• Consider implementing a “three strikes you’re out,” rule and terminate patients who are chronic no-shows.
• Excuse missed appointments if the patient is admitted to a health care facility due to illness or injury.
• State that future visits may not be scheduled until the missed appointment fee is paid.
• State that payment for a missed appointment is the responsibility of the patient, cannot be billed to Medicare or other insurer, and is due upon receipt of the bill.
• State that the purpose of the policy is to protect the practice from loss of “availability” to its patient population in medical need and assist in covering daily overhead cost of providing your services to the community.

Medicare Allows Practices to Charge for Missed Appointments

Medicare allows physicians to charge patients for missed appointments, provided they do not discriminate against Medicare beneficiaries but also charge non-Medicare patients for missed appointments. Medicare’s policy states that the charge for the missed appointment is not a charge for a service (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. The amount that the practice charges must apply equally to all patients, whether Medicare or non-Medicare.

A hospital outpatient department may charge a beneficiary for a missed appointment, unless the patient is a hospital inpatient who has an appointment in the outpatient department.

Medicare won’t pay for the missed appointment. The physician or supplier must bill the patient directly. This policy appears in the Medicare Claims Processing Manual, Chapter 1, Section 30.3.13.

How to Reduce No-shows

Instituting a policy to charge patients for missed appointments may reduce the number of no shows. Here are other methods of doing so:

• Make reminder calls. The calls should be 1 to 3 days prior to the appointment.
• Follow up on recent no-shows. Call each patient who has failed to make his appointment, and ask the reason for the missed appointment. Reschedule if necessary.
• Analyze no-show statistics. Determine which types of appointments are likely to be missed and the timing of those appointments. For example, in general a patient who schedules an appointment for 4 to 7 days in the future is more likely to keep the appointment than a patient who is given an appointment the next day or who schedules far in advance.
• Keep the office running on time. Patients who routinely wait more than 15 minutes to be seen are more likely to come late or not show for appointments.

Overbooking does not decrease no-shows, but it does decrease the lost business cost of no-shows. However, overbooking can lead to long wait times for patients, which could lead to increased no-shows.

Don’t Let the No-shows Fall through the Cracks

There is also a malpractice risk associated with no-shows. If a patient has been advised to return for further evaluation, and the patient’s condition is such that a failure to treat has dire consequences, and the lack of return visit leads to a failure to treat, then the failure to keep the appointment could cause the patient a bad outcome and could subject the clinician to a lawsuit. So, if a return visit or other followup is critical, a nurse or physician should not let the patient’s issues fall through the cracks. Call the patient and advise him or her of the urgency of followup, the time line that is advised, and the worst-case scenario if followup does not occur in a timely manner. Document the advice given.

Read more articles at Medscape.com.

Introduction

Physicians use clinical medical sites regularly, but more and more are also turning to social media — such as Facebook and online physician communities — for professional reasons or networking.

In general, physicians use social media to seek out clinical information and opinions and discuss medical points of view with other doctors; to increase their professional exposure among colleagues and the general community, and for purely social reasons — to stay in touch with family and friends.

Each type of usage has pros and cons for doctors and comes with some important guidelines. These guidelines can help you make sure the information you get is correct and can keep you out of trouble.

A famous cartoon from a decade and a half ago declared, “On the Internet, nobody knows you’re a dog.” That sense of anonymity still prevails on some parts of the Internet, but the advent of social media has turned the adage on its head. Put your name on Facebook or LinkedIn and people will find you. Contribute to a blog and yours might just become a household name.

Clinical help from online communities: how good is it?

Doctors can turn to a good number of online communities especially for physicians or other healthcare professionals. Some, like MedHelp, connect professionals with the public to answer health questions. MedHelp users often find this site by Googling the name of a medication, says Enoch Choi, MD, a family physician in a Palo Alto Medical Foundation urgent care center in Palo Alto, California. Choi dispenses advice on MedHelp and facilitates public discussions.

Other interactive Websites are restricted to licensed clinicians. Popular names in this sphere include Medscape Physician Connect, Sermo, and Ozmosis, plus many aimed at various medical specialties. Internationally, there are DoctorsHangout.com and several global imaging repositories, including a bilingual English/Spanish site for radiology called MedTing.

In the realm of wikis, the globally popular Wikipedia is pretty much a free-for-all. Anyone who signs up for the site can edit content that far too many people take as indisputable evidence. In 2006, comedian Stephen Colbert famously showed the downside of this grand experiment in information sharing by coining the term, “wikiality,” a combination of wiki and reality. “On Wikipedia, we can create a reality that we can all agree on — the reality we just agreed on,” Colbert said.

In healthcare, there tends to be more controls over the wiki editing process. At the recent annual meeting of the Medical Group Management Association, Greenbranch Publishing, publisher of the Journal of Medical Practice Management, debuted Codapedia, a clearinghouse of sorts for medical coding and reimbursement information. Anyone can register to use the site, but you have to get approval from the Codapedia community to submit information and edit existing entries. Additionally, each change gets reviewed by a registered editor

Medscape Physician Connect is an update of the popular message boards that have been a hallmark of Medscape.com since 1999. It has a physician board of advisors, and users must disclose their name and credentials; they cannot hide behind a cloak of anonymity. Similar rules apply for Ozmosis. Sermo is for sharing and seeking opinions on clinical information and other topics directly related to the practice of medicine. It allows “bookmarking” of interesting articles and other items online, similar to Digg or Delicious.

Choi describes Sermo as “the old doctor’s smoking room,” a virtual replica of the place where physicians used to hang out and discuss medical questions.

TogetherMD is a multidisciplinary, multispecialty online community for healthcare professionals of all stripes. In early December, it will add a physician-only mode.

Verification is a huge part of physician social networking sites. “They’re really trying to establish trust for their users,” says John Dancu, Chief Executive of IDology, an Atlanta-based company that provides identity and credential verification services for online businesses, including physician and patient portals. Both Sermo and TogetherMD are IDology customers. Medscape Physician Connect also verifies physician user identities.

Facebook: It’s everywhere

Choi has more than 3000 Facebook friends, many of whom are patients and colleagues. He also is a blogger and moderator on MedHelp, an online community for consumers, so he spends plenty of time using social media.

But he draws the line at talking about cases with colleagues or sending diagnoses or test results to patients on networking sites. “I can’t do any patient care using their messaging or using the site because it’s not HIPAA-compliant,” Choi says. “I’ll pick up the phone to discuss a case.”

Because doctors can be hesitant to share their e-mail addresses — and regular e-mail is not secure to HIPAA standards — it’s not unheard of for people to find their doctors on Facebook. But the doctors interviewed generally say they avoid making diagnoses or communicating test results over the Internet. Answering a medical question or acting on a request to refill a prescription might work, though.

Choi has no reservations about “friending” other physicians online, just about discussing cases. “Most of my interactions with them are social interactions,” he says. And he also relies on Facebook to keep up with friends from his residency. “We reminisce about 100-hour weeks,” Choi says. “It’s all old friends discovering you,” he adds. “It’s a lot of nostalgia.”

Choi also networks in his community, putting an Internet Age spin on the small-town mentality he developed while growing up with a physician father in Peoria, Illinois. “It’s a transition to an electronic means,” he says. “People don’t know their neighbors as much anymore.” Notably, he likes to connect with “mommy bloggers” to show that he treats the kinds of minor ailments that kids have so often.

He’s on the boards of some community organizations, and he also posts his speaking engagements on networking sites. “That’s another way to show who you are,” Choi says. “When you have these social interactions, it’s cool to see what people are up to.”

William Hersh, MD, Chair of the Department of Medical Informatics and Clinical Epidemiology at Oregon Health & Science University (OHSU), is also a Facebook user, mostly to keep up with friends and family. “I certainly have a lot of colleagues on there, but they’re colleagues who happen to be friends,” says Hersh.

“I tell people I have 3 distinct audiences,” Hersh says, referring to his colleagues, his college-age kids, and old friends from high school that he’s reconnecting with. “I don’t belong to that many groups on Facebook,” Hersh says. “To me, that’s not a real big connection.” Still, he has started fan pages for 2 OHSU programs. “We’re actually looking at ramping up the marketing [for OHSU on social networking sites],” Hersh adds.

He will occasionally post interesting articles, and he also puts up pictures from speaking engagements as well as vacations. He saves internal and professional communications for the OHSU network and e-mail system. Hersh also subscribes to American Medical Informatics Association (AMIA) listservs and gets feeds from groups on LinkedIn.

“What I think the physician really needs is a chance to connect with his current patients or his future patients,” Knopf says. “There’s an opportunity to get departments together.” Other benefits of social networking include better patient education.

Knopf has a Facebook account but mostly uses it for interaction with family and close friends. “There’s no reason that these professional networks can’t link into Facebook,” he says. LinkedIn already has some features integrated with Facebook, but the medical sites generally do not. Medscape Physician Connect, Ozmosis, Sermo, and TogetherMD all have pages on Facebook, though each has just a small number of fans, and posts on those pages tend to be news items about the networking sites themselves.

Because of HIPAA, users on most of these sites are not allowed to share patient-specific information, though items that have been stripped of identifiers generally are fair game. (Soon, TogetherMD users will be able to upload videos for complex cases, such as from cath labs and ultrasounds.)

“From every other standpoint, everything is community-regulated,” Byrne says. Registered members of many online medical communities, such as Medscape Physician Connect and TogetherMD, can flag information they believe is inappropriate. The site’s administrators will review the post for privacy and copyright adherence.

If you’re going to share clinical information online, people had better know that you’re a physician or a nurse or some other sort of health professional, or else don’t count on being trusted. They may not know if you’re a dog, but if you dispense medical advice, the public certainly does want to know that you’re qualified to do so.

Where You Need to Be Cautious

Hersh’s OHSU informatics program has students who are right out of college or medical school as well as some established physicians and health professionals who are coming back for informatics training. The school has published some guidelines about what’s appropriate and what’s not appropriate for posting on social networking sites, particularly targeted at the former group.

“I don’t think the younger people appreciate the permanence of Facebook,” Hersh says.

Indeed, a study published in JAMA in September said that 60% of US medical schools reported incidents of students posting inappropriate or unprofessional content on blogs, social networking sites, or other places on the Internet.^[1] Only 38% of responding schools said they had policies regarding publishing of online content — but most policies, according to the researchers, did not expressly state they covered Internet usage.

Another study, in the July 2008 issue of the Journal of General Internal Medicine, found that many University of Florida medical students were less than discreet with some of their Facebook pages.^[2] Some belonged to groups called “Physicians Looking for Trophy Wives in Training” or “PIMP: Party of Important Male Physicians.” Others were pictured grabbing the breasts of a female classmate, visibly drunk, or sporting a lab coat that said “Kevorkian Medical Clinic.”

Of course, physicians behaving badly is not a new concept, but for years, the risqué humor, alcohol-fueled hijinks, and derogatory slang in patient charts — think “CLL” for “chronic low-life,” “LOBNH” for “lights on but nobody home” and “grave dodger” to describe a chronically ill elderly patient — have been hidden from view. Digital images and electronic data potentially bring such embarrassments out into the open. What happens if patients start reading such language or viewing their doctors in compromising situations?

While the Internet creates many opportunities for increased communication of clinical data, it’s wise to keep your eyes open as to the source and credibility of any site you visit.

Read more articles at Medscape.com.