One of the questions I see pop up most often in the Abundance Practice-Builders Facebook Group (feel free to join) and in day-to-day questions I get from private practitioners is how to handle last minute cancellations and no-shows. I put these questions in two camps: the I-don’t-know-what-my-policy-should-be camp and the I-don’t-know-how-to-enforce-my-policy camp. Let’s talk about both.
What Should My Policy Be?
For the most part, you get to decide what your policy is. If you’re on insurance panels, read your contract thoroughly. They may dictate whether or not you can charge your clients for no shows and late cancellations. That sucks. If you aren’t on insurance panels or the panels you’re on give you free reign, I want you to consider a few important points in determining your policy.
- You are running a business. I want you to decide on your no show and late cancellation policy as if your practice is full. There will come a time when you are packed and have clients who want to see you but couldn’t squeeze into your busy week. Write your policy with this in mind.
- The policy is not meant to be punitive. I don’t believe in punishing or shaming clients under any circumstances. There is a distinct difference between coming from a place of punishment and coming from a place of boundary setting and maintenance.
Ok, so let’s talk specific no show and late cancellation policies. I’ll give you mine as an example in script form. It’s written clearly in both my informed consent and my financial policy forms but in the first session I say something like: “I know you signed a few forms before this appointment and to be honest with you, I don’t ever read those things when I’m signing them so I wanted to tell you the most important parts so we’re on the same page.” Then I do my limits of confidentiality spiel. Then I say some rendition of this: “The Financial Agreement is another form you signed. The basics of what it said is that you are responsible for payment at the time of service. I keep your credit card on file so if you forget it, it’s no big deal. If you need to cancel a session for any reason make sure you do so more than 24 hours before your session. This gives me a chance to contact the people who may have wanted a session this week but couldn’t get in. If you cancel within 24 hours or don’t show up for the appointment you are financially responsible for the full fee of the session, which is $150. [it’s important for you to lay out the price here. That way if the client is using insurance or on a sliding scale they understand that it’s not their $20 copay or sliding scale amount]. If you let me know within 24 hours and I’m able to get someone in that slot, I won’t charge you. I’ll use the credit card I have on file for any no show or late cancellation fees and will charge it during the session you’re missing. Do you have any questions about that?” (as always, if this script works, use it.) People never seem to have questions for me. If they were to question the policy I would reiterate that I often have people who want to see me that can’t and that I want to create space for the people who are eager to do the work. I don’t have a policy about how many no shows people can have simply because it’s never been an issue. My people show up or cancel well ahead of time. Being clear about my policy contributes to a sense of treatment buy-in.
Some people do a one no show or late cancellation freebie. I don’t. If my client calls and is sick, their kid is sick, or they were in an accident on the way to session I waive the fee. In my opinion it’s totally reasonable to waive the fee for these things.
If someone does no show I make sure we talk about it in the next session to see if it’s a relevant therapeutic issue. Again, not from a place of shaming or punishing, from a place of curiosity and support.
How Do I Enforce My Policy?
It’s A LOT easier, and more fair, if you do the verbal explaining on the front end. Here are a couple things to think about that may help you maintain your boundary:
- Remember that as the therapist, you are responsible for modeling boundaries. Remembering this has been invaluable not only as a clinician but as a business woman. So, if you set a policy, it is your duty to follow it. Yes, policies can change, but don’t change them simply because you’re not great a boundary maintenance. If it’s a growth edge for you, commit to working on that.
- You can sneak your financial policy in the informed consent and just let them sign it even though nobody reads it all. You can avoid the conversation. Here’s what will happen: the first time you try to enforce this boundary, your client will be confused. You will show them where they signed the consent. You will feel shady. They will pay the fee or try to negotiate with you. They may feel betrayed. It will impact your work together. Alternatively, you will feel too weird enforcing the policy so you won’t. Let’s avoid this dynamic. In your first session, after describing limits of confidentiality and any other intro to therapy spiel you have, tell them your policy in a matter of fact way. (see above). The first few times you may feel uncomfortable bringing up money in the first session. Money is a part of their experience with this; avoiding the uncomfortable experience of owning that isn’t great modeling for clients. We invite them to share very intimate, hard things in their lives. If they can tell you these vulnerable things, you can say the thing that’s hard for you around money.
Expect it to feel really uncomfortable the first few times you charge for a no show/late cancellation or have the conversation in the first session. You can tolerate discomfort.
What trips you up the most with no shows? What’s your policy? Let us know in the comments.
Allison Puryear is an LCSW with a nearly diagnosable obsession with business development. She has started practices in three different states and wants you to know that building a private practice is shockingly doable when you have a plan and support. After retiring her individual consultation services, she opened the Abundance Party, where you can get practice-building help for the cost of a copay. You can download a free private practice checklist to make sure you have your ducks in a row, get weekly private practice tips, listen to the podcast, hop into the free Facebook Group. Allison is all about helping you gain the confidence and tools you need to succeed.
Loved this blog! I felt very uncomfortable talking about money initially but as Allison suggested, get it out front during the intake interview – as I do with email and social media policies – and then it’s up front. The conversation provides clarity and opportunity for questions. Then everyone is on the same page with no surprises.
Thanks, Laurie! Yes, it’s a growth edge for many of us & I’m glad you’re over the hump!
I have a question about keeping their credit card On file and then charging it when they don’t show. Where do you securly keep their cards and don’t you need them to sign or approve the transactions? i am always trying to collect the fees after the fact. Thank you!
I use Simple Practice, which uses Stripe and stores it very securely. It’s not something you’d want hanging out in a filing cabinet, in fact I believe it is not legal to keep all of the information together in less secure ways.
Great blog post! Fortunate, my clieNTS HAVE PAID WHEN THEY MISS OR LATE CANCEL A SESSION. STILL, IT OFTEN FEELS UNCOMFORTABLE FOR ME. I DO NOT CHARGE IF THEY OR THEIR CHILD IS SICK OR THERE IS AN EMERGENCY, AS YOU MENTIONED.
I DO GO OVER MY 24 HOUR CANCELLATION POLICY IN THE FIRST SESSION, BUT I TEND TO RUSH THROUGH IT. I LIKE THE SCRIPT YOU SHARED AND IT FEELS BETTER TO ME. I WILL USE IT, THANK YOU! Professional growTh area 🙂
Um, not sure why this is coming out in caps! Sorry.
I dint have a problem with my out of pocket cLients. I have a few medicaid clients and usually they follow the cancellation policy. However, I’m not sure how to handle it fee-wise since it os not likely they can afford the full fee cancelation cost. Any suggestions?
I believe it’s written in the Medicaid contract that you can’t charge for no shows. I’ve never taken Medicaid, but I’ve heard this from several people. (Anyone with different info, please chime in.)
Medicaid does not allow a provider to charge late cancel and no show fees. I use the policy that if you late cancel no Show 3 times in 12 months, the client is discharged.
This is really helpful Teri 🙂
Correct – you can’t charge a missed session fee for Medicaid. The best alternative to prevent chronic problems with those clients is to do an attendance polIcy that says you will terminate and refer out after 2 no shows.
Great advice, Carolyn!
Hey, thanks as always for a super helpful post, Allison. I had something come up this week, and wasn’t sure how to handle it. If someone cancels late, and I don’t fill their spot, but they reschedule for another day that week since I had a cancellation,how do I charge? For both the missed session and the rescheduled one? (to further complicate the question, the spots she ended up filling was a Medicaid client’s spot, so I wouldn’t have charged that person for the miss anyway)… Thanks
There’s no right or wrong; it’s just what feels best to you, Lange. I know a lot of people who don’t charge if they still see them that week (and thus still have the same weekly income).
🙂
This is what I do. My policy is if I can fill the spot or they can come within the same calendar week then I waive the late fee. I specifically state this when talking with them about rescheduling.
Thanks Ruth. That sounds good to me too.
Ok, here’s another scenario I’m curious about. Just trying to get my personal boundaries in line here, but also trying not to be super stingy. I had a parent meeting scheduled this afternoon. Schools are on a 2 hour delay this morning (“snow”) and my client let me know they won’t make it because her morning work appt was moved to our scheduled meeting time because of the school delay. Normally with inclement weather I wave the fee, but just not sure about this one… thanks for anyone’s thoughts! (But just fyi, I didn’t charge…)
I wouldn’t charge, personally. All this “snow” (FYI to those not in our city… there’s literally none right now) put our family on a delay because of a late start at daycare so I know I’d feel penalized for something I couldn’t control if I was charged.
Ok, Thanks Allison.
Great post!
In my first year of private practice, I told the clients during the phone consultation that I had a 48-hour cancellation policy but felt too squeemish about saying that I would charge the full fee if they didn’t adhere to the policy (I left that for them to discover in the informed consent– which no one reads!) I found myself feeling SO uncomfortable enforcing my policy that I always gave a freebie for the first cancellation.
After feeling resentful and taken advantage of for a year and hating that conflict about whether to enforce it or not, I FINALLY overhauled my phone script and I now state my policy clearly, INCLUDING the full fee late cancellation part, and ask clients if they have any questions about it, and ask them if they agree to it.
This, I know, will save me TONS of headaches and deliberation.
I think this is a HUGE issue among therapists and you addressed it beautifully here.
Thanks Allison!
-Natalie
Hey Allison!
I’ve read this post multiple times because it helps me to read (and re-read!) these words when I have no-shows and late cancellations. Even after overhauling my script, I continue to have no-shows and late cancellations at times. I’m much better at charging the fees now, due to being more direct at the start of treatment, but every now and then I just find it excruciating to charge the fee, especially with newer clients. It’s something I continue to have a really hard time with.
Ok, I’m going to apologize up front for all caps; I can’t seem to get my laptop tO do lowercase letters here. I wanted to say wow; putting this into the perspective of “clients share really vulnerable stuff with us”.. so we should be brave in addressing this, which we probably all have discomfort around, was really eye-opening for me. Thank you so much!
Oh good, when the comment posts, it’s not all in caps; great I didn’t want anyone to think I’m yelling!
Hi Allison!
I love your perspective on this, but I struggle with how to do it as a dietitian where I don’t see people as often as you therapists. I see a lot of my clients just 1-3 times (some more of course too), so it doesn’t feel right to use up 5-10 minutes of the initial session going over the paperwork when I may not ever see them again. I list my policies clearly on my website and in appointment confirmation & reminder emails but still I encounter people who seem surprised when I uphold the policy. Any tips on how to best handle this?
Thanks!!
Good question- I’d do it anyway. While you may see them fewer times (and some counseling modalities are very short-term too so I’ll include those folks), it behooves you to say it anyway if you are going to see them more than once. My script takes less than 2 minutes so it doesn’t eat into the session time.
I Really appreciate this post as i’m trying to finalize my own policies for my practice.
Question:
Does anyone Offer discounTs for pre-paid sessions in bulk? I had A client ask about this rEcently. How Would you handle any potential cancellations/refunds if they decided to dIscontinue Treatment before they had used up their sessions? Are there any ethics guidelines here?
There are some ethical considerations in that you have to be fine with them ending early. Which basically means they don’t hold a lot of water, though they can be an effective way of making people commit more to treatment if they’re financially motivated. I don’t do packages because my people are going to stick around regardless of packages and I don’t see a reason to give myself a pay cut. 🙂
I’M STRUGGLING WITH INCLEMENT WEATHER – IN KANSAS WE ALWAYS HAVE WEATHER AND THIS WINTER IS NO EXCEPTION. HOWEVER TONIGHT FOR EXAMPLE, IT DOESN’T SEEM THAT BAD OUT, THEY HAVEN’T CLOSED SCHOOL OR EVENING ACTIVITIES AND I HAVE CLIENT WANTING TO RESCHEDULE FOR THE 3RD TIME – ALL DUE TO INCLEMENT WEATHER. SAFETY IS FIRST BUT I’M STRUGGLING WITH HOW TO HANDLE THE WEATHER CANCELLATIONS IN TERMS OF WAITING THE FEE.
Ugh! It’s so hard! I have a FB Live talking about what to do now that we don’t have paid time off. I recorded it the day after a snow day. You can find it here: facebook.com/abundancepracticebuilding/videos
Do you offer telehealth? i am able to do video chat so i have offered that as an alternative if safety is of concern.
in terms of a late fee, do insurance companies typically have a policy that in network Clinicians can only charge what they would be reimbursed? I have a client who is questioning this and i can’t find my contract for beacon health. don’t know this is all caps….