Dental patient no-shows: a reminder and deposit policy that works

In the ADA Health Policy Institute's April 2023 poll of 807 dentists, 81.3% named no-shows and cancellations inside 24 hours as the biggest thing keeping the schedule from full. Most practices answer with more reminder texts, or a fee on the new-patient form that nobody enforces. Neither is a policy. A policy is four things written down: how you count, how you remind, what patients agree to, and what the desk says when the chair is empty. Here is each.

Count them first, in three piles

A no-show and a late cancellation are different problems. Researchers led by Adrienne Lapidos of the University of Michigan analysed more than 180,000 appointments for nearly 46,000 patients at a large university's dental clinics and found that "canceled and failed appointments followed distinct or even opposite patterns." Appointments between 8 and 10 am were more likely to be no-shows; later ones were more likely to be cancelled. Visits booked for more than an hour were cancelled more often, nearly 30% of those over two hours. Medicaid and uninsured patients were more likely to do both.

That is a teaching clinic, not your practice, so run your own numbers. Pull the broken-appointment report from your practice-management software for the last 90 days. Open Dental, for example, charts code D9986 for a no-show or a cancellation without notice and D9987 for a cancellation with notice, so the report splits them for you. Make three piles: no-shows, cancellations inside your notice period, and cancellations with notice. Divide each by appointments scheduled. Then cut each pile by new or existing patient, appointment length, time of day, and how far ahead it was booked.

Each pile has its own fix. No-shows are mostly a reminder problem. Late cancellations are a policy problem. Cancellations with notice are a refill problem: the patient did the right thing and the chair still sat empty.

Reminders: what the trials say

• Reminders work, and texts work about as well as calls. A Cochrane review of eight randomised trials with 6,615 participants found attendance of 67.8% with no reminder, 78.6% with a text and 80.3% with a phone call. Two of the studies put the cost per attendance of a text 55% and 65% below a call.
• More than one reminder beats one. A 2016 BMJ Open review of 26 studies found no-shows of 15% with a notification against 21% without, and that multiple notifications raised attendance by 25%, compared with 6% for a single one.
• A voice still does something a text does not. In a 2011 Journal of the American Dental Association study of 317 caregivers at a university pediatric dental clinic, the group reminded by voice message had a no-show rate of 8.2%; the group reminded by text, 17.7%.

Put together, that is a three-step sequence. The reviews do not settle the timing, so start here and adjust against your own report:

1. At booking: a confirmation text with the day, time, length and how to change it.
2. Three working days before: a text asking for a reply to confirm.
3. The day before, by noon: a phone call to everyone who has not confirmed.

Two rules for the wording. HIPAA permits appointment reminders, but HHS says practices "should take care to limit the amount of information disclosed" in a message: the practice name, the time and a number, never the procedure. And the consent and frequency limits for reminder texts are in our new-patient phone script, where the desk asks for them.

The policy patients sign: five lines

The ADA's guidance is to write a clear cancellation policy, display it, put it in every new-patient package and have patients sign it. Its sample policy asks for "a minimum of 24 hours' notice" and says a fee "may be charged"; the guidance adds a warning: "Apply the penalty judiciously; charging a fee can strain the relationship." Five lines cover it:

1. The notice period. 24 hours or two business days. Say which, and what it means for a Monday morning visit.
2. What counts. Not arriving, cancelling inside the notice period, and arriving more than a stated number of minutes late.
3. The first time. A phone call and a new appointment. Nothing else.
4. The second time in twelve months. One consequence, chosen in advance: a fee, a deposit on the next booking, or a scheduling rule. A sample policy from the DentaQuest Partnership allows one broken appointment in twelve months; after a second, the patient is seen same-day or as a walk-in, not by advance booking. The ADA suggests rebooking habitual cancellers four to six weeks out.
5. How to cancel. A number that is answered, including after hours.

Deposits and fees: where they work, and who you cannot charge

A deposit is collected before the visit; a fee is chased after a patient has already decided not to come. So prefer the deposit, and use it narrowly: for long appointments (the pile the Michigan-led study found cancelled most), and for anyone on a second miss. Make it a credit toward the visit, refundable in full with notice, said on the phone and repeated in the confirmation text.

Then check who is exempt. None of this is legal advice.

• Medicaid patients. A 1995 letter from the federal Medicaid agency, still in HHS's guidance repository, keeps "the long-standing Medicaid policy which does not permit providers to bill program recipients who miss scheduled appointments," on the reasoning that a missed appointment is not a distinct reimbursable service but a cost of doing business. Colorado's Medicaid agency adds that providers cannot "ask members to sign forms accepting financial liability for missed appointments." In 2021 the Massachusetts attorney general's lawsuit against a dental provider cited a contract with a minimum $20 missed-appointment fee for MassHealth patients; Utah, by contrast, permits a charge under set conditions. Read your state's provider manual.
• In-network patients. Read each PPO agreement for what you may bill a member beyond copays and deductibles before the policy goes on your forms.

For patients you cannot charge, use the reminders, the confirmation call and the scheduling rule in line 4.

What the desk says

At booking, the policy is a courtesy, not a threat:

The day-before call to anyone unconfirmed:

After a no-show, the same day, concern before policy:

Make cancelling easier than not showing up

Some no-shows tried to cancel. Check your call log for the evening before each one: a call from that patient's number at 7 pm that reached voicemail is a late cancellation you turned into a no-show. Whatever answers after hours and at lunch should take the change, offer new times and tell the desk at once. An AI receptionist does that and sends a transcript within a minute, so the freed slot is visible at 7:45 am, not at 2:30 when the chair is empty. ClinicEcho is $497 a month with a 14-day free trial, and we sign a BAA before it takes a call. The after-hours call test shows what your patients reach now.

Then fill the hole. At every booking ask, "If an earlier time opens up, would you like a call?" and keep the yes answers on a short-notice list by appointment length.

Four numbers a month

No-show rate, late-cancellation rate, appointments still unconfirmed the day before, and freed slots refilled. If the first two fall and the fourth rises, the policy is working. Our cost per booked patient guide shows why "showed" belongs next to "booked" in the monthly report.

Frequently asked questions

Sources

• Becker's Dental Review, "Patient no-shows, cancellations still biggest hurdle for dental practice schedules" (May 2, 2023), reporting ADA Health Policy Institute poll, week of April 17, 2023 (807 respondents)
• DrBicuspid, "Study: 5 factors that affect no-shows and cancellations" (Aug 2, 2017), reporting Lapidos et al. in Public Health
• Open Dental, "Mitigating the Impact of Broken Appointments" (March 28, 2024; codes D9986 and D9987)
• Cochrane, Gurol-Urganci et al., "Mobile phone messaging reminders for attendance at healthcare appointments" (2013; 8 trials, 6,615 participants)
• Robotham et al., "Using digital notifications to improve attendance in clinic: systematic review and meta-analysis", BMJ Open (2016)
• DrBicuspid, "Voice reminders can reduce no-show rates" (April 4, 2011), reporting a study in the Journal of the American Dental Association, April 2011
• HHS, HIPAA FAQ on appointment reminders and messages left for patients
• American Dental Association, "Patient Cancellations" and its sample cancellation policy and scripts
• DentaQuest Partnership for Oral Health Advancement, sample broken appointment policy with letters
• HHS guidance repository, "1995 - billing & missed appointments" (HCFA regional letter, June 1995)
• Colorado Department of Health Care Policy and Financing, "Policy Statement: Charging Members For Missed Appointments"
• DrBicuspid, Michael W. Davis, "Ignorance isn't bliss: No-show fees for Medicaid patients" (July 8, 2021; Massachusetts and Utah)

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