Welcome to the Ethics Forum! The optometric profession has long recognized its ethical responsibilities to patients, colleagues, other health care professionals and the public. This forum provides an opportunity to review a hypothetical case study containing potential ethical challenges and includes suggestions on how one might handle the situation based upon the American Optometric Association Standards of Professional Conduct and Code of Ethics.

If you have any questions on ethics, please submit them to EthicsQuestion@aoa.org. The AOA Ethics and Values Committee will respond to your questions as soon as possible. If you have an ethical challenge you wish to share, please feel free to submit a case description to ethics@aoa.org. The case description will be reviewed by the AOA Ethics and Values Committee and may be featured in a future Ethics Forum.

Approaches for Medicaid Patient No-Shows

By Robert W. Moses OD FAAO

Case Study #7

Dr. Little practices in a low income area of a large metropolitan city.

The majority of her patients are enrolled in the state Medicaid program. Many of her patients receive medical care for a wide variety of health issues, including diabetes, hypertension, obesity, and depression. Many are also being treated for chronic eye health issues, such as glaucoma, high risk medication use, and diabetic and hypertensive retinopathy.

This morning, Dr. Little was happy to see her schedule fully booked. Her staff was assembled and ready to start.

After caring for her first patient, she discovered the next set of appointments, a family of three, had not yet arrived and were not answering a phone call placed by staff. As the day progressed, the pattern repeated itself-an all too familiar occurrence.

Of twenty patients, seven were no-shows. Dr Little reviewed the day sheet and wondered how long she could continue to operate her business or care for her patients if she could not reverse the trend.


Patient no-shows are a concern for all providers, but especially so for doctors with a significant Medicaid population.

No-show rates vary widely, but a study by the Illinois College of Optometry found in their clinics an average no-show rate of 24.8%. The rate for Medicaid patients rose to 41.25%.1 Another academic facility in Milwaukee found a 30% no show rate, but interestingly, that 12% of the patients accounted for 35% of the no-shows.2 High rates are a serious financial and health care concern for optometrists and patients alike. Missed appointments increase concerns about delayed or aborted care and potentially serious consequences for patients. Financial loss, staffing concerns, and equipment investment impact providers by this unpredictability. How can no-shows be reduced?

One study by the American College of Physicians3 found that keeping statistics on no shows can help reduce their frequency. The study found that patient appointment scheduling procedures (such as not asking patients for their preferred appointment times) affected one-third of the probability of patients not keeping appointments. Conflicts with other medical care, such as dialysis or late appointments when public transportation may not be available almost guarantees a no-show. Increased success occurred when patient concerns were taken into account and appointment times most convenient to the patient were provided.

Some offices resort to double or triple booking patients. The uncertainty of this approach is frustrating to doctors, staff, and patients alike. If patients do keep appointments, it overburdens staff and doctors, inevitably causing the schedule to fall behind and running the risk some testing might be delayed or eliminated. For patients, this creates long wait times and a feeling their time is disrespected, and may increase the probability of future no-shows or late arrivals. Another more focused approach uses data from no-show tracking to identify habitual no-show patients and uses double booking with that population.

Communication is another key factor in controlling no-shows.

Most offices attempt to confirm appointments, but may not be successful in reaching patients. Staff should identify the best way to communicate with patients at the time appointments are made. In many cases, cell phones, texting, or e-mail may be a preferred and more effective approach. Some offices have initiated automated phone systems which allow patients to confirm or cancel appointments and create reports or interface with EHR software. Claims of reductions in no-shows of 30% have been made by the vendor.4

Another important aspect of communication is to discuss the need for the appointment and answer any concerns the patient may have. Patients may not understand or may have forgotten the reason for their visit. Some have concerns about any testing that will be done. Responding to allay fears a test may hurt or may be outside of insurance coverage may help encourage compliance. Patients with chronic conditions, many of which may be asymptomatic, like glaucoma, or patients taking high risk medication or suffering from hypertension or diabetes, may not fully understand the importance of ongoing care.

One controversial approach attempted is to charge a no-show or cancellation fees. This is not generally permitted in the Medicaid population, although some states are beginning to require greater personable responsibility from Medicaid recipients.

In general, the potential to collect such fees from low income patients is limited. Patients will typically choose another provider for future care. It is much better to understand the patient's behavior and find a solution that will allow ongoing care and a better relationship. Another approach to reduce no-shows suggests advising patients of office policy resulting in patient discharge following two or three no-shows. Patients who miss appointments should be contacted immediately to determine why the appointment was missed and to reschedule as soon as possible. Clinical records should include missed appointments, reasons patient missed, and efforts to reschedule.

After each scheduled appointment resulting in a no-show, warning letters should be sent to patients reviewing the office policy. After a final no-show appointment (typically three in a 6-month period), providers should consider appropriate steps to discharge the patient from the practice.5/6

Managing a practice with a high Medicaid population requires finding a balance between the unique challenges of the patient base treated and the realities of sustaining a viable practice within the community and maintaining high quality care for our patients.


1. Sanford Gross, Eileen Gable, "Evaluation of no-shows in an optometric education Clinic," Optometric Education Poster 33, American Academy of Optometry 2002

2. Tito Izard MD, "Managing the Habitual No-Show Patient" Family Practice Management 2005 Feb; 12(2):65-66

3. Stacey Butterfield, "Research reveals reasons underlying patient no-shows," 2009 Feb: ACP Internist

4 .Robert Lowes, "Practice Pointers: How to handle no-shows," Medical Economics, April 22, 2005

5. Princeton Insurance, "When Patients Don't Return of Follow-up Care," July 2008, Reducing Risk, a Publication on Healthcare Risk Management

6. Bradley J. Johnson MD, Jamed W. Wold MD, MPH and Michael Pontiuos MD, "Reduction and Management of No-shows by Family Medicine Residency Practice Exemplars," Annals of Family Medicine, Nov. 1, 2007, p534-539

About the author:

Robert W. Moses OD FAAO

Dr Moses is the owner of a multilocation full-scope primary eyecare practice in Northwest Indiana. He is a Past -President of the Indiana Optometric Association and has served as Chair of the IOA's Third Party Care Committee for over 35 years. Dr Moses is Board Certified and is a Fellow of the American Academy of Optometry. Dr. Moses was appointed to the American Optometric Association Ethics and Values Committee in 2016.