The Dilemma of the Missed Appointment:
Can the Doctor Bill the Patient?

By: Ronald E. Nyman, Esq.

As carrier reimbursements continue to decline and malpractice premiums skyrocket, most practices have concluded that every moment of the day should be revenue productive. From charging patients for completion of school or camp health forms to billing for telephone consultations, doctors are faced with charging patients with services that were once considered gratis.

In line with the new economics of practice management, doctors and their staffs need to ensure that every moment of the day is filled with patient visits. As with most solutions to cure one ill, another arises in its place. In this case, can a doctor bill a patient for a missed appointment? I have heard this question repeated often within recent years and, time and again, I find myself without any concrete answer.

The problem is that the government, via its representative, the Center of Medicaid and Medicare Services (CMS), has issued no concrete directive whether a practice can bill a Medicare or Medicaid patient for a missed appointment. Most CMS bulletins deal with what services are covered or not covered for reimbursement. If a doctor provides a non-covered service to a patient for which Medicare will not pay, the doctor can bill the patient as long as the doctor has the patient sign a Waiver of Liability at the time of service. This document ensures that the patient is fully informed that Medicare will not pay for the doctor's services and that the patient agrees to pay the doctor's bill. However, in the case of the missed appointment, there is no CPT-4 code for missed appointment, and, more importantly, the patient cannot sign the Waiver of Liability since the patient missed the appointment.

With regard to the commercial carriers, there is also much confusion. If a doctor contracts, and, therefore, participates with a particular carrier, the doctor needs to review the carrier agreement to see if charging for missed appointments is prohibited. Even if there is no specific prohibition against such billing, I would still recommend contacting a provider representative at the carrier. Many carriers have attempted to argue that a doctor cannot bill for a missed appointment even if the carrier agreement does not prohibit it. Although the carriers' arguments appear specious, in many instances they are threatening doctors with removal from their network.

One additional complication arises when a patient misses an appointment for what would have been a covered service. For example, if a patient made an appointment for a preventative exam and the carrier would have paid the doctor $75.00 for the exam, can the doctor bill the patient for a missed appointment where the bill would be greater than the $75.00 reimbursement?

If the doctor does not participate with a carrier, then the analysis becomes somewhat easier. If there is no agreement between doctor and carrier, then the doctor should be able to bill the patient for the missed appointment.

Whichever course the practice ultimately takes, I would strongly recommend that a practice notify all of its patients of a missed appointment billing policy. This notification could include office signage in the waiting room, mailing notices to patients and having patients sign a document stating that they are aware of the policy. At the very least, patients will not be able to complain that the new policy was sprung on them without notice.

This article first appeared in the May/June 2004 issue of News Capsule, a publication of The Fairfield County Medical Association.