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Last-minute cancellations and no-shows are major hazards in private practice. If you’ve ever had clients who don’t make it to sessions, you know what a stressor this can be. With each missed session, treatment is disrupted, rescheduling takes time and effort, and practice income is lost. One of the best ways to prevent these stressors is to develop and implement an easy to follow cancellation policy in your practice. This policy can serve as a useful extension of the therapy you are already providing, reinforcing client consistency, responsibility, and accountability. By calmly adhering to the rules, you model stability and predictability. Clients are encouraged to take responsibility by paying fees they incur and to honor commitments in the future by following policy guidelines. For many people the message reinforced is to keep their needs and scheduled appointments a priority, even when others place last-minute demands on their time and attention.
For example, my colleague Tom quickly realized the value of enforcing his cancellation policy when his client, Sandra, called at the last minute to cancel her session. Sandra had suffered from severe depression all her life and was referred to Tom for psychotherapy by her prescribing psychiatrist. Her symptoms had worsened in the last two years as she became overwhelmed with multiple demands from her full-time job, children, husband, and extended family. It was hard for her to say no to anyone, so she spent almost all of her time attending to everyone’s needs but her own. Her husband and children had become accustomed to her attention and expected her to drop everything when they requested.
The day she cancelled her session, her husband had asked her at the last minute to stay home with him and the children, and as usual, she had quickly agreed. Soon after she called to cancel, Tom called Sandra back, reminding her of the cancellation policy and fee. Sandra shared this with her husband and he quickly changed his mind about wanting her to stay home, as he did not relish the idea of paying the full fee for Sandra’s missed appointment.
When Sandra arrived at her session, Tom therapeutically addressed her decision to cancel, relating it to a general pattern of forgoing her own needs at her expense. By enforcing the cancellation policy, he helped Sandra see that she deserved to set boundaries to preserve her time and attend to her needs. Although Tom had to enforce the policy a few more times, each time Sandra was able to reprioritize her needs and keep her appointment. She also started setting more boundaries on the job and with her children, and even joined a women’s gym. As of the last update, she was exercising three times a week and had lost thirty pounds. She had also just completed laser eye surgery, something she had always wanted but until then did not feel she deserved.
To help clients understand and remember your cancellation policy, keep it as simple and clear as possible. If you don’t already have a policy, one standard policy you can use requires clients to cancel at least twenty-four hours before their scheduled session or they will be charged the entire fee for the missed visit. A one-day cancellation timeframe has the advantage of appearing reasonable and not too difficult for people to follow. If you prefer, you could substitute forty-eight or seventy-two hours, or a different option individualized to your practice.
Although it’s fairly straightforward to develop a policy, it can be challenging to successfully implement your policy in everyday practice. When clients break policies, your reactions could also compromise your services and enforcements. If you are building a client base you may be afraid of alienating clients and losing them with restrictive rules. You may assume that by flexing your policies, clients will be more likely to continue in therapy. For example, you might repeatedly allow people to miss visits with no fee. However, consider that clients may still drop out of therapy whether breaks are given or not. And it’s possible that the more flexible you are with ongoing clients, the more likely they will repeat policy breaches.
One danger of waiving your policies is that you can start feeling negatively toward your clients. Over time your stress from disrupted treatment and uncompensated time can spill over to interactions with clients and decrease the effectiveness of your clinical work. By following policies you’ll help to prevent this stress from building and preserve the quality of your services.
For example, when I was getting started in practice, I was afraid that clients would become upset and stop coming if I appeared too rigid in enforcing policies. I assumed that flexing policies would preserve rapport and enhance therapeutic effectiveness. I often let clients slide when they called at the last minute to cancel or did not show for appointments. To my surprise, what I thought was the best approach lead to the opposite of what I expected. The very clients I had offered breaks frequently repeated policy violations and I felt more stressed each time. I started to have negative feelings about these clients during sessions, and soon became aware that treatment could suffer as a result.
After realizing things were getting worse with my lenient approach, I faced my fears of clients’ reactions and enforced policies. It was uncomfortable at first, and some clients that I had previously flexed policy with became upset. However, with time I became more comfortable enforcing policies, and clients responded in kind. My negative reactions to clients disappeared and my professional self worth and confidence grew. With fewer disruptions, therapy became more productive and my income and time were preserved. Now most people honor policies, and those who don’t quickly learn through enforcement and are less likely to do it again. The rare client who drops out frees time for someone else to be seen.
Small steps will help you to enhance compliance with your cancellation policy from the beginning. To start, explain your policy to clients over the phone when you are arranging for the first appointment. By establishing your policy right away, you will fully inform clients that they need to cancel sessions in advance or they will incur a charge for missed visits. This will help reduce last minute cancellations and no shows, and allow you enough time to schedule other clients in times that become available.
For example, my general explanation is, “There is also a twenty-four-hour cancellation policy. If for some reason you are not able to make the appointment, as long as you let me know more than twenty-four hours ahead of time, that is fine. However, if you do not, and you don’t make it to the appointment,—unfortunately insurance does not pay for missed sessions and—you will be responsible for the entire amount of ___ dollars—not just the co-pay for the missed visit—. You seem like a very responsible person and I don’t expect this to come up, but I wanted to let you know the policy right away just in case. Do you anticipate any problems with this?” You will probably find that most people are familiar with cancellation policies and quickly agree to call ahead if something comes up.
When starting in practice I did not review my cancellation policy during the phone call before the first appointment. I found that some first-time clients did not make it to their initial appointment. Because they did not yet know about the policy, they usually called to cancel at the last minute, leaving no time to offer the spot to someone else. After I started explaining the cancellation policy over the phone, I noticed a significant drop in the number of no-shows and last-minute cancellations. Consider too, that clients are often nervous and ambivalent about seeking help. A cancellation policy can provide the extra boost they need to follow through in making it to their sessions, especially if they get cold feet at the last minute.
To formalize the agreement, include the policy in the treatment consent form you give clients to read and sign in the first session. By placing the policy on the page that clients sign and date, they are more likely to read it when completing the form. The policy could read as follows:
Canceled/Missed Appointments
A scheduled appointment means that time is reserved only for you. If an appointment is missed or canceled with less than twenty-four-hours notice, you will be billed directly according to the scheduled fee or according to the rules of your health plan. Your health plan does not cover payment for missed appointments; therefore, you are responsible for payment in full.
Sometimes after introducing and reinforcing your policy, clients will still not show or cancel at the last minute. The simplest way to respond is to directly follow the policy and charge the full fee for a missed session. However, sometimes you may want to bend your cancellation policy based on the client, the situation, your personal style, or any other factor. There are a variety of ways you can be flexible with your policy while still following general guidelines. If you choose an option, share it only at the time you offer it to clients. This will prevent clients from expecting policy breaks and allow you discretion to follow the policy exactly or bend it if you choose.
One way you can be flexible with your policy is to waive cancellation fees for emergencies. If you do this, decide ahead of time which situations are severe enough to qualify as emergencies so you will have a guideline to follow later. Some scenarios will be obvious emergencies. However, many other situations clients present will not be so compelling or obvious. By setting your emergency criteria ahead of time, your task of enforcing the policy will be much easier when different events occur.
One emergency criterion you can use is an immediate physical injury or major trauma to the client. Typical examples include a hospitalization, involvement in a car accident, victim of a crime, serious illness/injury, and self-referral to urgent medical care. The same crises happening to one’s children also qualify, given that the client is actively involved in securing help for the child.
For example, one such crisis happened to my client, Rebecca, a single mother of three. She was rushed to the emergency room the morning of her scheduled appointment when her autoimmune disorder (Sweet’s Syndrome) took a life-threatening turn for the worse. Fortunately, Rebecca made it to the hospital in time for critical treatment and was able to go home a few days later. In a situation like this, there is no question of an emergency.
When emergencies happen in your practice, if you offer clients a fee waiver, explain that this is a one-time exception to your policy and that they must call in advance to cancel appointments in the future. This will help reduce future missed visits by reminding clients that your cancellation policy is still in place. You can still reserve the option of allowing future emergency waivers based on individual situations and your criteria. Here is an example of what you can say to clients after therapeutically responding to their immediate crisis needs:
“As you know, there is a twenty-four-hour cancellation policy and full fee required for the missed visit. However, because this is an emergency, I can waive the policy and fee this one time so there is no charge for this missed visit. However, for future sessions the policy will remain and you will need to call at least twenty-four hours in advance if you need to change your appointment. Would you like to schedule another session?”
Another way to amend your cancellation policy is to offer a substitute session later that day or within the next day or two. Clients receive a big break by not being charged for their missed appointment and treatment continuity is preserved. You also fill an open time that might otherwise go uncompensated. When offering this option, present it as a one-time courtesy to remind clients that the cancellation policy still applies for the future. You can also state the specific cancellation fee for added policy reinforcement.
Imagine that your client, Diana, calls right before her session to cancel, saying she was just called to pick up her son from soccer practice early because he was in a fight. He wasn’t hurt but was disciplined along with the other boy and told to go home. You could say, “Since there is the twenty-four-hour cancellation policy—and insurance doesn’t pay for missed visits—your fee is ninety dollars. However, I do have an opening tomorrow afternoon at 3 p.m. If you are able to come to that appointment I can waive your cancellation fee.”
If Diana can come to the appointment and tells you that she appreciates the fee break, you could respond with, “I’m glad we could reschedule your appointment this time, but if you cancel less than twenty-four hours again I cannot guarantee that I will have an opening. The cancellation policy will still be in effect and you would owe the full fee for the missed session. In your case the amount due would be ninety dollars—since insurance will not pay for a missed visit—”.
These are some of the small steps that you can take to establish and implement a successful cancellation policy in your day-to-day practice. By proactively reducing last-minute cancellations and no-shows, you’ll reap big benefits in preserving continuity of care for your clients. You’ll also reduce the stress of rescheduling sessions and maintain your practice income, allowing you to provide quality care to clients as long as you desire.
Holly A. Hunt, Ph.D. is a psychologist in private practice in Southern California. Her article was first published in The Therapist, (July/August 2005) and is adapted from her book “Essentials of Private Practice: Streamlining Costs, Procedures, and Policies for Less Stress” W.W. Norton, 2005. For more information visit www.EssentialsOfPrivatePractice.com.
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