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    Nate Moore
    Nate Moore, CPA, MBA, FACMPE

    Medical practice leaders understand that the appointment creation process and getting patients in the door — physically or virtually — is what drives your revenue cycle.

    What is sometimes more difficult to understand, as the COVID-19 pandemic eases across the country, is what are truly the biggest challenges to optimize your providers’ time, bring patients back and limit unfilled spots on the schedule.

    A March 15, 2022, MGMA Stat poll asked medical group leaders their biggest challenge with appointments. Availability/wait times was the top answer (46%), followed by no-shows (38%), cancellations (11%) and “other” (5%). The poll had 505 applicable results.

    Among those answering “other,” the most frequent responses included:

    • Having appropriate staffing levels to handle rising patient demand for care.
    • Patients who deferred care during the pandemic presenting large lists of concerns that cannot be addressed in the allotted time or during a well visit.
    • Providers being unwilling to open blocks on their schedule.
    • Limited waiting room space due to COVID-19 guidelines (and patients unhappy about waiting in their cars outside).
    • Lack of accurate clinic grids for scheduling.
    • Higher rates of last-minute cancellations, even in practices that charge fees for them.

    We know many patients deferred care in the past two years, and there are still some patients who might be anxious about coming back to see the doctor. The strategies for winning over those patients is a story for another day; what I’d like to focus on is what medical group practices do each day that can influence your rates of no-shows, cancellations and other scheduling hiccups that can have a negative impact on your bottom line.

    Measuring appointment capacity

    At the 2021 Medical Practice Excellence: Leaders Conference, we devoted a session, “Front-Loading Your Revenue Cycle,” to answer a simple question: “If you can see things coming as part of the appointments that are scheduled or not scheduled, can it affect the rest of your revenue cycle?”

    The simple answer is, “Of course,” and it begs an even better question: What is your practice doing to block appointments or block patients from getting into this revenue cycle?

    Consider how appointments are templated in your system. Look closely enough and you can understand the total amount of available hours that each provider is scheduled over the course of a week or month to derive a denominator — the hours of provider capacity available.

    That time will vary by specialty and location, as well as other provider-specific variables, such as time blocked for medical directorship or administrative duties. You want to know the number of hours that are truly schedulable.

    In one practice I described at the conference, the advanced practice providers would notice that a Friday schedule looked a bit light and got the front desk to move all the Friday appointments to the morning and then block the afternoon off, with the understanding that they would open it back up if they needed the space.

    You’d hope the practice management (PM) system wouldn’t allow this sort of activity, as it limits the capacity and reduces the ability to see patients. But the solution is also in the PM system, as you can look back at your data and see where those blocks occurred. You might have to determine whether things were blocked on the template, via a specific appointment type or other methods, but your appointment availability might be much broader than your past activity would suggest.

    Especially if you have a provider whose wRVUs or compensation metrics aren’t where they ought to be, I suggest looking at that availability and rethinking the blocks in the schedule to give them the opportunity to earn and your patients the best access you can offer.

    Is your practice causing some no-shows?

    It’s easy to blame individual patients for no-shows, throw your hands in the air and say, “It’s out of our control.” But there are ways in which practices cause no-shows that you can work to avoid.

    For this, you’ll need a bit of graphing expertise. Look at your practice’s historical no-show percentage — for example, 2%, 4%, 6% — and graph it on a Y axis. With the X axis, plot the number of days from when the appointment was scheduled to the date of the appointment: In other words, from the date the appointment was scheduled to the date of the appointment, how many days passed?

    The first thing you’ll see is that no-show rates will increase over time. Consider a dermatology practice: A patient calls about a skin issue and is told it will take two weeks to be seen; they book the appointment and then call around to find someone who will see them sooner, and then forget the original appointment. The longer we drive wait times for providers, the higher the no-show rate will be.

    Source: Even Better Data, Better Decisions— Advanced Business Intelligence for Medical Practices by Nate Moore.

    The figure above shows that graph for an orthopedic group in the Midwest. Notice the spike every seven days or so: A provider was telling patients, “If it still hurts, come back and see me in four weeks.” The patients would book that appointment for four weeks out, knowing it might be difficult to book closer to the four-week mark.

    When things don’t hurt in four weeks, the patient doesn’t come back — just as they were told to do. Seeing this data allowed the physician to change the script a bit: “If it still hurts in four weeks, call and we’ll make sure we get you back in.”

    Now consider an orthopedic practice that automatically schedules post-operative visits a certain number of days following a surgery. But sometimes a surgery is cancelled or postponed due to the patient not getting medical clearance or an issue with prior authorization.

    Your PM system knows that post-op visit is still out there, and you can look for post-op appointment types to determine if there is a surgery associated with that visit. Another method to get at this issue is searching by your post-op visit (99024) codes and looking back nine or 10 days in that global period for the procedure. If that procedure isn’t there, you’ve got a problem. I use SQL Server to automate this search.

    Ensuring that these connected elements of care delivery are addressed together and not forgotten will help you find availability you didn’t know you had and help you see patients sooner, reducing the chance of a no-show.

    Each of these instances represents money inadvertently left on the table by medical practices, but a careful look at your data can turn those missed opportunities into revenue.


    Our ability at MGMA to provide great resources, education and advocacy depends on a strong feedback loop with healthcare leaders. To be part of this effort, sign up for MGMA Stat — by texting “STAT” to 33550 or visiting — and make your voice heard in our weekly polls. Polls will be sent to your phone via text message. 


    Nate Moore

    Written By

    Nate Moore, CPA, MBA, FACMPE

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