It can be a tricky situation. When a client misses an appointment or calls to cancel too late for their spot to be re-filled, how should a clinician handle it?
For a psychologist, especially one in private practice, missed appointments create a dilemma. On one hand, the therapy relationship can be a delicate one, based on trust and a sense of partnership. On the other hand, a missed appointment means wasted time and a loss of income for the psychologist and a disruption of care for the client.
“If you are a psychologist, especially one in independent practice,” said Gerald P. Koocher, Ph.D., ABPP, Senior Associate in Psychology at Children’s Hospital and Lecturer at Harvard Medical School who teaches a continuing education course on ethics, “you are not able to recover that time. It goes back to the days of Sigmund Freud, who described it as the patient ‘leasing’ the clinician’s time.”
Two methods for handling missed appointments have become common: the automated reminder system and missed appointment fees. While neither method will completely eradicate the problem, the new tools have helped psychologists with administrative issues and clients with remaining on schedule with treatment.
“I have very few missed appointments. Maybe one per week out of 30 or 40,” said Eric Jackson, Ph.D, a clinical psychologist with a private practice in Orange, Connecticut. He uses an email reminder system and his policy states that he will charge for missed appointments, except in cases of illness or emergency. “I rarely do charge them.”
Jackson has found that allowing for one missed appointment before charging generally weeds out early treatment clients who are not committed to keeping to a schedule. Up until recently, however, Jackson did not accept insurance. With the addition of Connecticut’s Medicaid plan, Husky Health, he has found his no-show rate starting to creep up.
“I have noticed since accepting Husky that the percentage has gotten a bit higher,” he said. He hopes, however, that informing clients that they will have to pay a $100 fee out of pocket should help. “Insurance won’t cover it so I hope that notifying them and ‘scaring’ them up front will keep that from happening often.”
He has hit on a key component in the discussion of the ethicality of charging for missed appointments. Policies can range – from charging a full appointment fee to a fraction of the cost. Some will even charge for appointments missed during the therapists’ scheduled vacation time. It is all ethical and legal if, and only if, it is clearly spelled out and signed by the patient or guardian.
“You have an ethical obligation to clarify at the start of the relationship what all the contingencies are,” said Koocher. “The patient has to understand and agree.”
In some cases, psychologists get into trouble by being too nice. They won’t charge for a missed appointment when the client was sick but will charge when he simply forgot. It is a good idea, say experts, to let the client know in writing that an exception has been made this time and to include a written reminder of the policy.
Whatever policy a therapist chooses – no charge, a small fee, one waived appointment, the full rate – the client can still complain or register a complaint with the state licensing board if they feel slighted. That does not mean, however, that the complaint will stand.
“Complaints [to the board] are not that common for this type of billing,” Steven C. Atkins, Psy.D., chair of the N.H. Board of Psychologists, “and if there is the informed consent, then the board would look to see if this was clearly noted and signed by the client and/or guardian. No complaint would be ruled in.”
By Catherine Robertson Souter