Missed Sessions: The Cost of Being Too Nice - Navigating the Insurance Maze

Missed Sessions: Being Nice Can Cost You Thousands

by Barbara Griswold, LMFT (Updated August 29, 2022)

What if I told you that you could be earning thousands of dollars more in your practice — without doing any more work? Well, read on.

In my consultations with therapists nationwide, we strategize on how to keep more of their hard-earned money — without working harder. While there are many factors we can’t control, I am struck by how often these therapists are leaving thousands of dollars on the table each year due to one thing they can control: enforcing their cancellation policy.

It’s true, insurance generally won’t cover missed/late-cancelled sessions, and shouldn’t be billed for them. EAPs also don’t usually allow you to charge for a no-show, or it may count as one session (but check your contract: some EAPs do pay for no-shows, depending on the employer account).

However, if you are in-network with the client’s insurance, you can usually charge THE CLIENT for a missed or late-cancelled session, unless your contract forbids it (as with EAPs or Medicaid). You may only charge your insurance contracted rate, and you must have gotten the client to sign your cancellation policy in advance. Out-of-network therapists can charge clients their full fee for a missed session — again, as long as the client signed something in advance acknowledging your missed-session fee.

And not charging for missed sessions can add up to thousands of dollars in lost income each year. Do the math: Imagine you didn’t collect on one missed or late-cancelled session each week, then multiply that fee by the average number of weeks you work in a year. That’s how much income you lost last year by not collecting on missed sessions. If you charge $175 per client, and work 48 weeks a year, that is over $8,400 you lose each year if you don’t collect for missed sessions. If you didn’t collect for 2 missed sessions a week, that income loss would be $16,800 in a year.

So why aren’t we charging clients regularly for missed sessions?

Yes, it’s tough to charge for missed sessions. We are compassionate — we know clients are busy, and things come up. We want to be seen as kind and flexible. We want to see ourselves as kind and flexible. We feel guilty charging for a session when no service was provided. And while we spend our days encouraging clients to express feelings, the truth is we really don’t want them to be mad at us, and maybe even end treatment.

But would we question an airline that charged if we didn’t show up for the flight? A hotel that charged for a late-cancelled reservation? So why don’t we think of a missed therapy session in the same way? In all cases, the client’s late cancellation means the business doesn’t have time to fill the reserved space, and loses money.

I challenge you today to stop paying for the chaos in your clients’ lives. Each week, you will have a certain amount of income lost due to sudden emergencies and illnesses (yours or theirs) or unfilled hours, and you don’t need to add to that.

Also, a firm cancellation policy serves a therapeutic function: It role models clear boundaries, and challenges clients to make therapy (and themselves) a priority. When we set a clear rule like a cancellation policy, and then don’t enforce it, what is the message we send? I would argue that since therapy is often about healthy re-parenting, boundaries that are loose or aren’t enforced out of fear of conflict are not helpful to your client’s growth.

5 Tips to Earn More Without Getting More Clients:

Have a clear cancellation policy and communicate it to clients, both verbally and in your treatment contract. Identify exactly what the missed session fee will be, and if you are in- network for their insurance, that they must pay more than a copayment.
Enforce your policy — consistently. Otherwise, as with inconsistent discipline in parenting, we encourage boundry-testing by clients.
Know your exceptions. I don’t charge when the client couldn’t cancel in advance (ex. client emergency or waking up sick). I DO charge for work conflicts, because I don’t want to make it easy for a client to put work before self-care.
Charge the full amount you would have collected for the session (if you are in-network with their health plan, charge the full insurance contracted rate). Otherwise, why are YOU taking a loss for THEIR missed session?
Don’t allow a session to be rescheduled later in the week for free. The client is essentially taking two of your slots and paying for one. Also, it sets up an expectation for the future that they can reschedule easily.

Some Other Tips:

When a client late-cancels, remind them: Say, “I’m so sorry — I know you’re busy, and I hate to charge in full for a session when you won’t get the benefit. So if there is any way you can make it I hope you can work it out.” I can’t tell you how often they say, “oh, well, never mind, I’ll be there.”

If they are unable to come due to work: Say, “I hate to charge you, but I can give you an invoice for the missed session and you might be able to get your company to reimburse you.” I’ve had a client be reimbursed by her company.

I STRONGLY recommend you take down credit card information at the intake so you can charge for missed sessions as they occur. This often makes the payment feel less painful for the client. Also, even if the client is unhappy about being charged, or even if they drop out of treatment, you will be paid.

Feel you could use more coaching about the business side of your practice? Schedule your consultation with Barbara at www.calendly.com/barbgris