Should we start charging for no-shows?

The fee question usually arrives at the end of a bad week — three empty chairs, one of them a ninety-minute block. The impulse is justice: they cost us, they should pay. Before the policy meeting, it's worth being precise about what fees can and cannot do.

What a fee actually fixes

A fee deters the deliberate no-show — the person who decided not to come and didn't bother telling you. That's a real population, and for them, skin in the game works. It also funds a fraction of the loss when it does happen. That's the whole list.

What a fee cannot fix

The forgotten appointment — the largest no-show category at most practices — is untouched by fees, because the forgetful never made a decision your fee could enter into. The conflict-with-no-exit no-show is untouched too: the patient whose shift changed needed a reschedule door last Tuesday, not an invoice today. And the fee actively damages the derailed-but-loyal patient relationship — the $50 you collect from the mom whose kid got sick can cost you a five-figure lifetime value and a pointed review.

The order of operations

Build the maintenance first: instant confirmation at booking, a reminder ladder with a tappable reschedule path, backfill for dropped slots, kind rebooking follow-up for misses. That system catches the forgetful AND the derailed — the recoverable majority. THEN, if a measured residue of deliberate no-shows remains, a clearly-communicated fee policy is a reasonable backstop, and by then it lands on exactly the population that deserves it.

Practices that reverse the order tax everyone for the sins of a few — and keep the empty chairs, because the majority of no-shows were never deliberate.

Find out which population you actually have

The free score shows which maintenance steps your flow is missing; the $500 discovery measures what your booked patients actually receive, timestamped. Most practices discover their "flaky patients" were mostly un-maintained bookings — a fixable, and far cheaper, diagnosis.