Ep. 110: Proofing Your Practice Against Cancellations
Tried double-confirming, automatic reminders, cancellation fees…and yet you’re still experiencing cancellations and no-shows? This week, Sabri Blumberg joins us to do a deep dive into the reasons patients cancel and how you can eliminate cancellations once and for all in your practice (on both the doctor’s and hygienist’s schedules).
Links:
Guides for Filling Openings On the Doctor’s and Hygienist’s Schedule - https://mgeonline.com/filling-openings-on-the-schedule-downloads
DDS Success (coupon code RX269) - https://ddssuccess.com
Fees & Plans Analysis - https://www.mgeonline.com/fees-and-plans
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Questions From This Episode
Why is the schedule so important in a dental practice?
Few businesses run on 10 or 15 minute increments the way a dental practice does. The schedule is the architecture for the entire day, week, or month, determining production, collections, staffing, and how the day actually plays out. When cancellations or no-shows hit, especially last minute ones, the damage ranges from a minor dent to a fully wrecked day, depending on how many appointments are lost.
Is a high cancellation rate really a patient problem?
Not usually. Most doctors assume cancellations come down to bad patients, low dental IQ, or people not valuing their appointments, as if it's out of their control. One practice started double booking its entire hygiene schedule, essentially 16 patients booked for an 8 patient day, to compensate for no-shows, which only created longer waits, patient frustration, and less time for the doctor to see each hygiene patient properly. The real fix is figuring out whether the root cause sits with the front desk on the hygiene schedule or with sales on the doctor's schedule, then putting one person in charge of solving it.
What's usually behind no-shows and cancellations on the doctor's schedule?
It's typically a sales and finance issue. If a patient hasn't fully addressed how they'll pay for treatment before the appointment, they're more likely to back out once the bill becomes real. The fix is getting the finances of the treatment fully worked out, and ideally paid, before the patient is even scheduled. Once a patient has prepaid and committed, they tend to work around life's disruptions instead of canceling.
What steps actually prevent hygiene no-shows?
Put one person in charge of the hygiene schedule, train them to frame appointments as reserved and owned by the patient rather than something that still needs confirming, and build a confirmation protocol that starts several days out instead of the night before. A text or automated reply-to-confirm works fine for routine cleanings, but a real phone conversation is worth it for larger procedures, since people are far less likely to cancel on a live call than on a one tap confirmation.
If a same-day opening happens anyway, how do you fill it?
On the hygiene schedule, start by checking for a same-day patient who could shift into the open slot, asking confirmed patients if a family member also needs a cleaning, expanding an existing procedure, or reaching out to the executive list, patients who chronically miss appointments and can be called last minute. On the doctor's schedule, prioritize production opportunity over an unproductive procedure, like calling back patients whose treatment plan was presented but never accepted, framed as a complimentary follow-up to confirm things are still stable. Those consultation visits often close, since just coming back in shows real interest.
Episode Transcript
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Jeff: Can you think of any business where the schedule is as important as it is in a dental practice? Outside of healthcare, can you think of any other business that runs on 10 or 15 minute increments? Probably not. The schedule is the architecture for the entire day, week, or month. It determines how much you're going to produce, how much you're going to collect, how your day is going to run, and who's going to be where and when. So when you end up with cancellations, especially last minute cancellations, or full on no shows, it can wreck a day, a week, or a month. The degree of wreckage depends on how many cancellations and no-shows you have. It could be a minor dent or a fender bender, or it could be completely totaled. So how do you proof yourself against cancellations and no-shows? What steps should you be taking to protect your office, whether you're having problems or not? And if you do end up with a last minute cancellation or a no show, what steps should you take to fill those slots, whether it's on the doctor's schedule or the hygienist's schedule? That's what we want to talk about in this week's episode.
Jeff: My name is Jeff Blumberg, and I'm your host. I'm joined this week, as I have been many times, by Sabri Blumberg, the Deputy Chief Operating Officer here at MGE. Sabri, I think we have you all set up.
Sabri: I am. Hi, Jeff.
Jeff: Hello. If you haven't heard Sabri before, and you probably have if you've been listening to the podcast for a while, she's in charge of all of the technical delivery here at MGE. She's worked with thousands of clients and is our senior voice on client guidance around practice growth and efficiency. I thought talking to Sabri would make the most sense for this topic, since she has the most experience dealing with it across our clients.
Sabri: Thank you. Well, you have, you can't deny it.
Jeff: Well, you have, you can't deny it. Okay, let's roll right into this. Let's start with proofing yourself against cancellations and no-shows. Say I'm a client and I'm having a cancellation or no-show problem, maybe on the doctor's schedule, maybe on the hygiene schedule, or both. I'm assuming some of these steps are universal for both schedules, and some are specific to one or the other, since the hygiene schedule doesn't have much variance in procedures, while the doctor's schedule can be all over the place.
Sabri: Correct. So if you came to me having cancellation problems in both places, the first thing I'd point out is that when I talk to clients about cancellations, they usually assume it's the patients. That patients are just bad, or don't show up, or have low dental IQ, or don't think dental appointments are that important, as if it's something they can't do anything about. That's when you start seeing unusual solutions. I saw a practice a few weeks ago that was double booking hygiene, scheduling two patients in one slot, because their cancellation problem was so bad. They thought that was just how you handle patients who don't keep their hygiene appointments.
Jeff: Were they double booking the entire hygiene schedule? So if a hygienist normally sees eight patients a day, they were booking sixteen?
Sabri: That's correct.
Jeff: What happens if two people show up at the same time?
Sabri: They just deal with it, or they figure the schedule will even out because of cancellations later in the day.
Jeff: That might work in the short term from a production standpoint, the hygienist stays busy, but from a goodwill and PR perspective for the patients, it's eventually going to upset people because they're stuck waiting.
Sabri: Exactly. You're not only creating a scheduling problem where patients have to wait, you're also creating a problem where, if two people do show up at once, the doctor doesn't have time to see that many hygiene patients properly. Now the doctor's time with each patient is limited, which limits the treatment you get out of hygiene. And they weren't being scientific about it either, they could end up double booking two patients who both need an exam at the same time.
Jeff: Sorry, I get pretty deep into this stuff.
Sabri: The biggest takeaway is that they're solving the wrong problem. That's a front desk problem, an internal problem. It's very rarely a problem with the hygienist herself. Sometimes you'll have a hygienist who shouldn't be doing hygiene because she doesn't connect well with people, but that's rare. Usually it's not that the hygienist isn't educating the patient enough either. Usually the issue is on the front desk. So sorting out a cancellation problem starts with recognizing it's an internal problem, not a patient problem. The next step is realizing that problem belongs to somebody specific, not everybody. Responsibility for making sure hygiene patients show up should sit with one person on the front desk, so you know exactly who to talk to.
Jeff: Let me ask about that, since it's a good point to bring up. We've talked before on the podcast about how there always has to be one person responsible for something, whether it's new patients or anything else. In a lot of practices you have three people at the front desk and everybody does a little of everything, so nobody's really responsible for anything. So if I make one person responsible for the hygiene schedule, in a smaller practice I'm assuming they'd also be responsible for the doctor's schedule.
Sabri: Absolutely. But the reasons behind doctor no-shows are usually a bit different from hygiene no-shows, which is why I'm separating them.
Jeff: Okay, so hygiene no-shows are usually a front desk problem. What about doctor no-shows or cancellations? What are the usual culprits there?
Sabri: Usually that's a sales problem. The patient has agreed to the treatment, but the finances haven't been fully addressed, or the patient hasn't paid yet. When the appointment day arrives, the patient realizes they're going to have to pay, and that's when they back out. You want the finances of the treatment fully figured out, and ideally paid, before the patient is even scheduled.
Jeff: So say it's a larger procedure, three onlays and two crowns, maybe a $7,000 or $8,000 treatment plan. In that case, the doctor presents the treatment with the treatment coordinator, financial arrangements are made, and it's possibly even prepaid before we get the patient scheduled.
Sabri: Correct.
Jeff: But say we don't get paid, we just tell the patient they can pay the day they come in. Then I wake up that morning as the patient and realize I have to bring $6,000 to the office because my insurance is only covering $1,500. I'm going to call and say I don't feel well.
Sabri: That's correct. And that's not really a front desk problem, that's a sales problem. If somebody has prepaid for their services, you have a much better chance of them showing up. Sometimes things change in life, someone gets excited and commits to treatment, then goes home and their water heater breaks, or their spouse talks them out of it, and they decide to put it off. But if they're already prepaid and committed, they'll usually find another solution to whatever life throws at them.
Jeff: Got it. So most of the time, no-shows and cancellations on the doctor's schedule are a sales issue, though there could be a front-end mistake that contributes too. But on hygiene it's a scheduling and front desk issue. And again, in a smaller practice, it's likely the same person is responsible for both schedules. So the first proofing step is having someone responsible. What's next?
Sabri: The next step is training that person on how to handle it, and that breaks into two areas. First, they need to know how to schedule hygiene patients correctly. The biggest problem I see is that we schedule a patient for a day and then say we'll call to confirm it, which tells the patient, in their mind, that the appointment isn't really confirmed yet.
Jeff: Right, it's like saying, I've scheduled you six months from now, but don't worry, I'll call to confirm.
Sabri: Exactly. It's a matter of making sure the patient understands that this is their appointment. You'll call to remind them, but you expect them to be there, because a disappointment is important. It's not a confirmation call, it's a reminder call, a courtesy.
Jeff: I can see that. If you tell me, this is your appointment on August 6th at 2pm, we'll send a reminder text or postcard beforehand just to remind you, that tells me I own that appointment. Versus saying we're scheduling you for this time and we'll call to confirm it, which makes it feel like there's no responsibility on my end, it's all on yours.
Sabri: That's exactly right. And especially in a private practice, I usually let the patient know we're reserving this time for them, and if anything changes, to please give us plenty of notice, but as of right now, this is their appointment. If you send a reminder a month out and the patient wants to change it, that's not a big deal, there's plenty of time to fix it. But you've put some responsibility on the patient.
Sabri: So first, train your front desk to make sure appointments are scheduled correctly. Second, make sure the person making confirmation calls knows what actually counts as confirmed. Is leaving a voicemail confirmed? Is a text confirmed? I'd say you need to actually speak to the individual, or their parent or responsible party.
Jeff: If somebody tried to confirm my appointment and spoke to you instead, since we have the same last name, I'd probably consider that okay.
Sabri: Even in that case, you're taking a risk. Leaving a message asking someone to remind their spouse about tomorrow's appointment isn't confirmed. That leads to the next point: you need to give yourself enough time to confirm these appointments. You can't start the evening before. A few days ahead is ideal, and you need to speak to every single patient, even if it's a text exchange back and forth.
Jeff: That's how I confirm my own healthcare appointments now, typing C to confirm or Y to confirm, or doing it by email.
Sabri: Right, and even with those automatic confirms, it's a lot easier for someone to blow off an appointment when all they did was type a letter into a text, versus when they spoke to a real person on the phone or in a text conversation.
Jeff: Let's look at that. I'm not trying to devalue a hygiene appointment, and you may disagree with me here, but unless I had a real problem, say four cancellations a day out of an eight-patient hygiene schedule, I'd want to talk to everybody. But if I was only getting the occasional cancellation and things were rolling along fine, I'd be comfortable with a Y or C from a text or email. Versus, say, a large procedure like the onlay and crown case I mentioned earlier being on the doctor's schedule, I'd want to talk to that person directly, because losing that has a lot more effect on the practice than losing one cleaning.
Sabri: I understand what you're saying and I agree. The only thing I'd add is, if you're using an automatic text service for this, keep an eye on it, and if it isn't working, step back to an actual person handling it.
Jeff: That makes sense.
Sabri: The other thing is, whoever's handling confirmations needs to know how to handle people who are trying to cancel. It can't just be okay, sorry. They have to be able to say something like, we have that time reserved for you, is there any way we can fit it in, what can I do to help? Especially with same-day cancellations, they need to be able to push back politely and ask what's happening that's making the patient feel they need to cancel.
Jeff: So say I'm the kind of person who tries to blow off an appointment when I can. I call and say, listen Sabri, I'm really busy today, I'm sorry, I can't make it.
Sabri: I'd say I totally understand, but we do have this time reserved for you, only for you, and ask if there's something happening or any way we can make this work, since that time is set aside specifically for you today.
Jeff: So say I push back and say I'm just really busy, is there any way you can do it at three o'clock instead, and it's only an hour, we'll have you in and out.
Sabri: Then I'd say, awesome, we really appreciate it. So it's not so easy to just blow off the appointment. If you let the patient off the hook right away and say, okay, let me reschedule your next appointment, you end up spending half an hour later fixing that opening. It's much easier to spend the extra three minutes on the phone to see if the patient can keep today's appointment. Usually once the patient understands they're creating a negative effect on the office, and once they realize it's a private practice that doesn't double book and this time is reserved exclusively for them, they often change their mind, because people are usually nice and don't want to cause that problem. So we're ratcheting up the pushback in a polite way, and how much we push depends on how close we are to the appointment. If I'm calling a month ahead to reschedule, that's no big deal at all.
Sabri: So to summarize: first, someone needs to be in charge. Second, that person needs to be trained on how to schedule and how to confirm. Third, you need a good confirmation protocol, whether that's postcards, texts, or calls two weeks out, a week out, and definitely the day before. We actually lay out a full example of a confirmation system for both the doctor and hygiene schedules, including when to book over somebody, in the scheduler course on our online platform, DDS Success.
Jeff: I'll put a link on the episode website. My shameless plug.
Sabri: If you have a different system that works for you, stick with it. But whatever protocol you use for hygiene confirmations, it has to be in writing, it has to be followed, and it has to give you enough time to fix openings. You can't start confirming the day before or two days before as your first attempt, it doesn't leave enough time to fill the schedule. If you're deploying text, email, and phone calls at different points leading up to the appointment, you'll typically catch 60 to 80 percent of patients before you even need to make phone calls.
Sabri: For new patients on the hygiene schedule, I like to have the hygienist personally call them, usually at the end of the day, the beginning of the day, or over lunch, no more than two or three calls, just to introduce herself and let the patient know she's looking forward to meeting them, and ask if there's anything she can do to help them be better prepared.
Jeff: So say it's the end of the day and I have a patient tomorrow at 11, and I'm the hygienist making that final call. Would I do that even if the patient's already confirmed?
Sabri: Yes, sometimes that call is the confirmation. So I'd call and say, hi, I'm Jeff, the hygienist from Dr. So-and-so's practice, I'll be meeting you tomorrow when you come in to get your teeth cleaned, is there anything you'd like me to be aware of, or anything you want to discuss with the doctor while you're here? I'm looking forward to meeting you tomorrow.
Sabri: It's interesting, a client brought this up at one of our owners' conferences. He was having a new patient no-show problem, these were patients coming in to see him personally for an initial exam, not on the hygiene schedule. He started calling new patients himself the night before, and it eliminated his cancellations, because in a lot of cases the patient's reaction was disbelief that the doctor himself was calling. The provider who's actually going to see the patient calling them personally, which takes maybe ten minutes, has a tremendous impact.
Sabri: One last thing: if there's a larger procedure happening in hygiene that the patient will have to pay for, like a night guard or scaling, make sure that patient is prepaid, just like you would on the doctor's schedule. If I'm doing an arch of scaling and root planing that's going to cost $800 or $900 and the patient isn't insured, that needs to be taken care of before they leave the appointment where it was diagnosed.
Jeff: Got it. So that's how we cut off the bleeding so this stops happening going forward. In the second half of the episode we'll get into what to do once you actually have a last minute cancellation or no-show. But are there other things you'd recommend to reduce cancellations or no-shows on the doctor's schedule specifically, beyond getting patients prepaid and sold before they come in?
Sabri: No, those are the main things: prepayment and good confirmation. The doctor's schedule is usually simple if you have the patient prepay. Some practices tell patients that in order to reserve a time, they need to be prepaid. Others take a softer approach and say that since money is one of the more unpleasant parts of getting dental work done, they like to get the finances out of the way up front so everyone can focus on the treatment itself. You have to find your own words, and you might offer something like a 5 percent prepayment discount if that's comfortable for you. For the clients I work with personally, getting the dentistry prepaid is usually one of the first things we put in place, and the patient needs to pay eventually anyway, so it makes sense to get it out of the way.
Sabri: One thing worth mentioning: patients are becoming more savvy about financing. A lot of them know that no-interest financing through companies like Cherry, CareCredit, or Sunbit costs the practice somewhere around 10 to 15 percent depending on the company. Some clients who already offer a prepayment discount have had patients ask them directly, since financing would cost the practice about 10 percent, would the practice give the patient 5 percent off for paying in advance instead. And since the doctor already has a 5 percent prepay discount in place, that works out fine.
Jeff: That makes sense. And if you don't want to use a finance company at all, you can just tell the patient that if they pay cash, you'll pass along what the financing would have cost you. But you'd want to make sure you're not so heavily invested in PPOs that your reimbursement is bad enough to eat into your profit on top of that.
Sabri: Also, and this isn't something I've seen much in healthcare but I have seen in other businesses, I wouldn't charge a patient more for using a credit card. I believe in most merchant agreements you're actually not allowed to.
Jeff: I'm not an attorney, so don't take that from either of us, but the idea is that Visa, Amex, and MasterCard want people using their cards and don't want practices discouraging that. I've seen businesses charge a check price and then a few percent more for a card. Honestly, the difference is so small compared to a 10 percent financing hit that I'd just let the patient use a credit card if they're prepaying.
Sabri: And the other thing worth considering, not to get too off track, is that if you're that financially tight, look at whether your fees actually match what they should be. If you're stuck in insurance plans that keep your fees too low, start figuring out how to get out. Plenty of practices do it, and it's not as difficult as people think. As another shameless plug, we do offer a free fees and plans analysis where we evaluate a practice's fees and how to exit plans they're in. I'll put a link to that on the episode webpage too. It's a free appointment with one of our practice management specialists.
Jeff: So that covers how to proof the practice against cancellations and no-shows. Now let's get into what to do once you actually have one. I know you put together a whole framework on this for DDS Success, with a different approach for the hygiene schedule versus the doctor's schedule. We have handouts on both, nine steps to fill a last minute opening on the hygiene schedule, and about five steps for the doctor's schedule, and we'll make both available on the episode webpage. Do you want to cover the bigger points?
Sabri: Sure. On the hygiene schedule, you're just trying to fill the opening. Most people are familiar with the basics. First, check whether there's a patient on the doctor's schedule who's also due for a cleaning and could be moved into the open hygiene slot. Second, when confirming patients, ask if anyone else in their household needs a cleaning, though that only works if you're confirming ahead of the day, not filling a same-day opening. Even same-day, you can check whoever's being seen right before or after and ask if another family member could come in. Third, look at whether someone already on the hygiene schedule for something like a scaling could have their procedure expanded, though with insurance patients you have to watch the six-month timing rules closely.
Sabri: You can also check whether there's someone next week in the same time slot who could move up to fill this week's opening. And on DDS Success we keep what we call the executive list, patients who frequently miss appointments because of work or because they're just bad with schedules. We just tell them we'll call when we have an opening and see if they can make it last minute. Beyond that, you fall back on the more standard options, calling your overdue list, your fail list, or pulling someone up from later in the day. The more time you give yourself, the better your odds of filling it.
Jeff: So that's hygiene. What about the doctor's schedule, say the doctor loses a large procedure in the morning and now has two hours open?
Sabri: With the doctor's schedule, I'd always rather fill it with an opportunity than with an unproductive procedure, meaning someone who could either generate production or who the doctor needs to talk to about a treatment plan they might commit to.
Jeff: So say we've exhausted the usual options, nobody in hygiene needs a procedure the doctor could pull them into, no new patients are coming in with opportunity, and we've called tomorrow's and the next day's patients to see if anyone can move up, and we've struck out.
Sabri: Then instead of pulling forward a productive procedure from tomorrow, I'd rather the doctor spend that time on a potential opportunity for production. I'd rather have the doctor selling, with a chance to convert same-day, or even if they don't convert same-day, at least securing future production. That's often just as valuable as production time itself.
Jeff: So where would you be looking, new patients, incomplete treatment plans the doctor presented in the past that never got accepted?
Sabri: Exactly. Say you have a 10:30 opening on the doctor's schedule worth about $3,000 in production. You've checked hygiene for outstanding treatment to convert, checked for new patients, and there's nothing there. At that point I'm calling patients from what we call the incomplete treatment list, people the doctor presented treatment to a few months back who said they needed time to think about it. I'll call them in for what's essentially a consultation appointment, a nice way of saying a sales appointment, the same way the executive list is a nice way of saying patients who don't show up.
Jeff: Walk me through that call. Say you saw me three months ago, the doctor presented some crowns I needed, and for whatever reason it didn't move forward, and I went on with my hygiene appointment as scheduled. Now you have a 10:30 opening this morning, what do you say?
Sabri: I'd say something like, hi Jeff, this is Sabri from ABC Dental, how are you doing today? The doctor wanted me to reach out. Do you remember when you were here last, the doctor talked to you about those crowns you needed? I know that's a big decision, and until you're comfortable making it, the doctor just wants to make sure everything is staying stable. He has an opening today at 10:30 and wondered if you could come in so he can take a look. It won't take long, maybe half an hour, and it's complimentary, no charge.
Jeff: So that's the last shot after everything else has been tried.
Sabri: Right. Every once in a while, when you call someone from that incomplete treatment list, they'll say they've been thinking about it and are ready to move forward, but that's rare. The thing I always say is, if the doctor couldn't close the case in person, the front desk isn't going to close it over the phone. But at minimum, you get that patient back in for a consultation to make sure everything's stable, and of course it's not really stable, since it wouldn't have been diagnosed otherwise, but it gives the doctor another chance to talk to the patient, take another look, and point out that it hasn't gotten better and may be getting worse. Maybe the patient commits, maybe they don't, but there's a shot. And in my experience, once a patient actually comes in for that consultation, they usually do move forward, because going through the trouble of coming back in shows real interest.
Sabri: For your incomplete treatment list, the person who should really be working that consistently is your treatment coordinator. If someone on that list is overdue for a cleaning, I'll usually just get them in for hygiene and the doctor can revisit it while they're there. If they're not overdue, say they were just in three months ago, I'll call them back in specifically for that quick consultation look. And if the patient says they'd rather wait until their next scheduled cleaning, that's fine too, just make sure they're on the books for their recall and that they know it'll be checked again then.
Jeff: This is great, this is exactly where we'd want to start, proofing the practice so I'm not scrambling at the last minute. But sometimes a last minute cancellation happens for a legitimate reason, a family emergency, an illness, it's going to happen. So it's good to have some tools in the toolbox for when it does.
Sabri: Exactly. But if it's happening an unusual amount, then you know you have an internal problem, and it's an easy one to fix. It's either a sales problem if it's the doctor's schedule, or a front desk problem if it's the hygiene schedule, meaning either the person handling it isn't trained for the job, or nobody's actually been given responsibility for it.
Jeff: This is awesome. Don't forget, we mentioned the link to our online platform, DDS Success, on the episode webpage, along with the link to the free fees and plans analysis, and the two handouts Sabri wrote for DDS Success on filling the doctor's schedule and the hygiene schedule. Sabri, thank you so much for being here this week, I really appreciate it.
Sabri: No worries, this was awesome.
Jeff: And folks, that's all I have for you this week. If you want to find out more about MGE, you can find us online at mgeonline.com or call us at (800) 640-1140. Have a great week, and we'll see you on the next episode.