This is a series of 12 blogs written at the request of CodeQuick to help Medical Practice Administrators optimize the revenue cycle within their practice. Please contact C Business Services if you have any questions or would like more information.
Appointment scheduling is the most complex, non-regulated, system in a clinic. Why? Because we made it so. The process has become so complicated for most scheduling teams that they need a decision tree whenever it comes time to schedule an appointment. I’ve seen the instructions for scheduling be 16 pages for an eight-provider office and a spreadsheet that was printed on legal-size to assure that every scenario was covered! No wonder the clinical staff is often complaining that the schedule has been “messed up.” It should be noted by everyone in the clinic that the schedule is the gateway to revenue. The more complicated and convoluted this step, the less likely the schedule will be fully utilized and potential revenue will go right out the door. Therefore, the goal should be to reduce the complexity of appointment scheduling thereby optimizing the schedule for full revenue potential.
There can be many reasons why appointment scheduling in the clinic is complicated. At times it is because the clinic staff or providers have imposed rules that create variations in the schedule. This could be based on the time the staff or provider believe it takes them to perform a certain type of visit. It may be related to the way the staff sees the appointments in the back of the office. They do not look at each appointment’s full notes taken by the scheduling staff on why the patient is coming in. Instead, they quickly review the short-hand coded “visit reason” and prepare the exam room based on this. Therefore, the many different reasons for the visit in the system are just a “cheat sheet” for the clinical staff and providers. If a clinic is to remove this as a reason for the variety of appointment reasons, then the notes in the appointment, regarding why the patient is coming in, would become of utmost importance. Not only would the scheduling team need to become more detailed in their note taking, the clinical team and providers would need access to these notes and read them prior to seeing the patient.
Another reason for variation may be due to the electronic practice management (EPM) system, EHR, or automated reminder system the clinic uses. Many of these systems tie certain commands, documents, or automated workflows to they visit reason listed in the appointment schedule. An example might be the reminder system that sends out an email to patients with pre-visit paperwork.
The steps to uncomplicate the appointment schedule are basic in their descriptions. However, each step will take time, the ability to think outside of the box, and the readiness for change in the clinic.
- Determine the reasons for variation – clinic created or scheduling system created?
- Reduce the number of visit types – create based on the normal, not the aberration
- Allow patients to identify and know the length of visit needed (then add in time needed to meet pre-visit goals)
If an administrator and staff can think outside of “the way we’ve always done it,” then there can be ways to minimize the number of visit reasons in the system and still maintain the needs of the electronic automation. One example would be to make the reason for visit descriptors and codes extremely generic, such as “follow-up.” This would allow this visit type to be used in many different situations and the paperwork attached to such visits could be equally as generic. Does the clinical staff and providers utilize the information on the specific forms the patients fill out prior to the visit? Or do they instead just re-ask the same questions and enter the information into the medical record, ignoring the form the patient took the time to fill out? The answers to these questions may allow a clinic to move to a lower number of visit reason types.
To reduce the number of appointment types is the ultimate goal. This would make it easier for the scheduling team to schedule appointments. The elimination of a decision tree when scheduling appointments then leads to a team that can focus on more important goals – better utilization of the schedule. A clinic’s goal should be to lower the number of appointment types to five or less. The Institute for Healthcare Improvement suggests that primary care practices only have two appointment types:
- Short appointments for return visits
- Long appointments for physicals and new visits
And that the only decision that the scheduling team has to make is regarding whether the patient’s provider is in the office or not. If not, they are to ask the patient if they are willing to see another provider or wait until the provider is next available. Thus, the patient is seen when they want to be seen and the complexity of scheduling an appointment is removed. I suggest at least a third type of visit may also be appropriate – Long appointment for visits with an in-office procedure.
Another way to reduce the complexity of visit scheduling would be to ask the patient how long they would like to spend with the provider. A recent Medical Group Management Association (MGMA) report regarding patient access and scheduling found that 53.2% of patients stated that being aware of the amount of time of their appointment would change their attitude about appointments. Over half said that they sometimes or rarely knew how long their doctor appointments would be. One wonders if patients were told their appointments were going to be 30 minutes in total, and they should expect 15-20 minutes with their provider, if they would:
- be more likely to show up on time/early,
- be prepared with their questions for the provider, or
- be more forthcoming when scheduling the appointment on the exact reason for coming to their visit.
Once the complexity of the schedule is understood, an administrator must review the utilization of the schedule. Openings in the schedule due to no-shows, same-day cancellations, or inefficient scheduling are missed opportunities for revenue. Clinic teams must do what they can to limit or eliminate these openings. The MGMA Patient Access report showed that the median no-show rate for most specialties was 5%. Assuming that the average revenue per visit is $357.50 (Community Health Center Chartbook June 2017), this could be well over $82,750 lost revenue a year per FTE Physician (based on 2017 MGMA Cost and Revenue Survey production data). In an October 2017 MGMA Stat poll asking what members biggest challenge with appointments were, 44% stated no-shows, 38% said appointment availability, 7% unfilled slots, and another 6% for cancellations.
Better performing practices have found that their no-show rates have increased substantially the farther out the appointments are made. Those made within 7 days are likely to have a less than 6% no-show rate. Those scheduled in under 2 days will have a 2% no-show rate. This is why the Agency for Healthcare Research and Quality (AHRQ, government agency supporting PCMH) has encouraged the concept of an ‘open access’ schedule where same-day/next-day appointments are available. While there still will be patients that do not show to these appointments, the percentage is less than those appointments that are booked days in advance.
Another solution to reducing the no-show rate is calling/texting/emailing patients to remind them of their appointments. There are many electronic and automated systems available for clinics to utilize for this. Including, West Interactive/Televox, PhoneTree, and Stericycle. Even some other software systems, such as Phreesia and Updox, have these reminder systems included as part of their supplied package. Administrators should investigate the software systems currently in use at their clinic for these add-on features to see that they are fully utilized. Better performing practices find that communicating in with patients in a variety of methods (not just a phone call), is the best way to help remind them of their appointment. Any method of reminders to patients should allow them to confirm, reschedule, or cancel the appointment. Reminders should also be done at least a day before (not the night before) the appointment. This will allow the clinic to backfill any newly opened slots in the schedule.
While some clinics have tried charging fees to those patients that no-show or same-day cancel their appointments, the results have not been conclusive regarding the effectiveness of reducing no-shows. Some of this is due to payers not allowing insured to be charged a fee (administrators should read their individual contracts). Others have noted that patients rarely read and remember the financial policy stating that such a fee exists. Therefore, if they don’t know about the fee, then it is not the deterrent it is planned to be.
Once a clinic is able to find ways to reduce the complexity of the appointment scheduling process and involve patients in their own appointment scheduling then the scheduling team will be able to better utilize the schedule (not leaving inadequate openings or scheduling appointment incorrectly). At the same time, the clinic should utilize available resources to reduce no-shows and same-day cancellations. This includes reminder systems and scheduling appointments within a week or less. Appointments that need to be scheduled further out should be put on a reminder system for the clinic or the patient to call and schedule. If a clinic is able to accomplish both of these goals (easier scheduling and reduced no-shows) then the appointment schedule will be optimized for revenue capture!