Managing patient no shows are a big problem, with many clinics facing no-show rates as high as 30%. This has been an even bigger problem during the COVID-19 pandemic. Every missed visit affects the bottom line. Just as important, if not more so, missed appointments don’t affect just the schedule and the revenue—they affect your patient’s health.

No-shows and patient-initiated cancellations are both problematic. Cancellations are typically much more common and costly. On a gut-level, no-shows are more annoying.

Every no-show costs money with decreased revenue despite continued overhead expenditures. New patients who do not show up not only have a higher initial appointment value lost, but there are also future losses associated with the missed follow-up appointments and tests. We need to minimize no-shows. Occasional patient no-shows will inevitably occur, but we must not tolerate them.

First, we have to understand what causes a no-show. Then we must limit the occurrence of no shows and mitigate the effects of the few that remain.

Causes of Patient No Shows

Patients fail to appear for appointments for many reasons. Some causes of no-shows can be mitigated; others are destined to occur.


Easy access to the clinic is important. The further out an appointment is scheduled, the more likely a no-show will occur. The patient may forget the appointment (even with reminders), decide that it is not important, find another provider, or most troubling, suffer a catastrophic event related to the reason for referral. The difference between being able to see a new patient in a week vs a month is dramatic in cutting the no-show rate by half!

Inconsiderate patients

Some people are simply inconsiderate. They will schedule appointments and then not show for that appointment. A single occurrence of this means little, but recurrence should not be tolerated.

Economic reasons

Some patients do not show for economic reasons. They may say they could not miss work or the travel time would result in too much-missed work. Although these reasons may be true, they do not excuse the no-show. Another issue may be the cost of the office visit, such as copays and deductibles. A patient should still contact the clinic to cancel the appointment and provide an explanation in these cases. Nevertheless, financial concerns will be used as a reason for the no-show.


Finding a ride to an appointment can be a challenge for some individuals. Again, this is a valid consideration. In most cases, the patient should still be able to notify the clinic that transportation was unavailable. This may still result in a no-show appointment because the notification was made on short notice. This is especially true of delays related to traffic accidents or weather affecting travel.

Lack of reminders

Lack of reminders can be difficult to remember appointments, especially for the elderly, those with numerous appointments, or with appointments scheduled further out

Managing patient no shows

We must address no-shows and patient-initiated cancellations. Simply put—some things help and some do not. First, we will address strategies that help limit the number of no-shows, both now and in the future.

Do not continue to reschedule habitual no-show offenders.

Rescheduling people who make a habit of not showing up is financially detrimental to the practice. It can also result in the use of appointment slots that might be filled by patients who will arrive on time for their appointments. Set a number of no-show appointments that seem reasonable to tolerate. Typically, three or four visits is an adequate number. If a patient exceeds that remember to terminate the relationship appropriately.

Appointment Waitlists

Create and use patient waitlists. Waitlists can be managed by staff but require constant supervision and administration. Automated systems must work seamlessly and achieve the results desired. Filling slots is not the goal. Filling the appointment slot with the appropriate type of patient at the appropriate time with the needed information is the goal.

Relationships Matter

Develop a program of patient engagement for new and follow-up patients. Engaged patients are much more likely to keep scheduled appointments. Positive energy creates a sense of community, even before the relationship has actually been established. Small touches matter. Sweat the small stuff, and the big stuff will often take care of itself.

Encourage Cancellations

If your schedule is full, identify patients who do not need a follow-up appointment. Reschedule their appointments to open up time for a new patient encounter.

OnDemand Schedule Management

On-demand scheduling is an important part of a good cancellation and no-show mitigation strategy. Having to wait for the scheduler to cancel or reschedule an appointment isn’t exactly optimal patient engagement. This is an unfortunate necessity in an instant-gratification society. A good scheduler can create a positive experience even in a trying situation.

Open Access Scheduling

Leaving a portion of the schedule available for new patient appointments can be helpful. Some sources suggest leaving 30% of the schedule open for new patient appointments. This is, however, a very personal decision based on the type of practice, available staff, and personal preference. Leaving some slots open for urgent work-in appointments is certainly beneficial.

Automated Patient Appointment Reminders

Manual reminders can help avoid missed appointments but is a very labor-intensive approach. Automated systems could reduce the effort if they worked well and created a positive patient experience. Many systems that have been used to automate the process all too often they fall short— either creating a suboptimal schedule or yielding a patient experience that leaves much to be desired.

What not to do

Next, we have to review scheduling practices that are unhelpful or of minimal benefit. The last thing you want to do, is make the problem worse.

Direct Scheduling

Direct scheduling seems like it would enhance patient access and reduce no-shows. However, direct scheduling performed by the patient is a missed opportunity to engage the patient and build your relationship. Scheduling without engagement with the office limits the patient’s interest in the appointment. Make sure the patient has a reason to keep the appointment. Do not leave this to chance.

Online Scheduling

Depending on the system being used, online scheduling can help, have no impact, or dramatically worsen the no-show rate. It can even limit the number of appointments being made. A variety of issues can arise from online scheduling systems including the creation of duplicate appointments. Such issues create a negative patient view of the practice, which can result in negative online reviews or bad word-of-mouth advertising. Do not give patients a reason to become annoyed before you have ever met.

Too many reminders

Automated reminder systems can be effective, but a repetitive annoyance is another thing altogether. If a system becomes a bother, the patient may decline the reminder or may become disenchanted with the office (and the doctor).

Charging for No-Shows

Charging for new patient no-shows has risks. Announcing that there is a no-show fee to new patients can send a bad message at a time when patient engagement is especially important. There is such a thing as bad publicity. A few annoyed patients rapidly cost you more than the no-shows that were being addressed.

Double Booking

Double booking a certain number of patients may help recoup the average number of patients missed because of no-shows. Unfortunately, this method cannot predict the time or even the day of the no-shows. Double booking is a sure method of creating rushed visits, poor patient engagement, and hurt feelings. This not only upsets patients, but it will also add stress for you and your staff.


Empty appointment slots are a problem, regardless of the cause. We must manage patient no shows as well as patient-initiated cancellations. You can decrease the number of new appointments missed. More importantly, you can make sure you are optimizing your schedule over the long-haul.