Since my diagnosis of prostate cancer, I have been seeing a lot of doctors. This has opened my eyes to many aspects of the patient experience and made me reconsider how best to serve patients on several fronts. This has been a humbling experience, and I like to think it is making me a better doctor.

This week, I got a bit of a surprise. As I checked in at my new PT’s office, the receptionist smiled at me and said, “Just so you know, for future visits, there is a $65 no-show fee.” I was taken aback. I’d encountered no-show fees before, but $65 was the highest I’d ever seen.

After seeing my PT, she smiled and reminded me again: “We’ve scheduled you for visits once a month for the next four months. Remember, if you can’t make your appointment and you don’t cancel 24 hours in advance, there’s a $65 no-show fee!”

The logic behind the policy is compelling, I must admit. By introducing no-show fees, patients are more likely to attend their medical appointments, ensuring they receive the care they need. Moreover, the incentive to cancel in advance rather than not show up helps free up appointment slots for other patients in need. Without this policy, these appointment slots would remain unused if a patient fails to cancel in advance.

But, at the same time, could these very high fees disadvantage low-income and disabled patients, who may be more likely to miss appointments due to circumstances beyond their control, such as transportation challenges? These are the same patients who are most acutely harmed by being charged for care they didn’t receive. Exploring how no-show fees influence patient trust and ongoing engagement can help balance operational needs with patient relationships. Perhaps an escalating fee based on the number of missed appointments would be fairer.

In my clinical experience, I’ve witnessed the challenges posed by no-shows. While implementing a no-show fee policy can be a potential solution to this issue, the consequences can be complicated. Such a policy may inadvertently target vulnerable patients, particularly those dealing with unforeseen circumstances. For example, a single mother with a sick child or a patient facing an emergency might miss an appointment and be burdened by the fee. This could discourage them from seeking care in the future.

I wondered how many patients no-showed for this PT practice. Was this the result of a high incidence of no-shows in the practice’s history? Did the steep no-show fee encourage patients to complete their PT treatment, or did it put patients who couldn’t pay at a disadvantage?

No-show fees, although technically legal, are among the many areas where doctors must thoughtfully balance competing considerations for patient well-being. To write this article, I asked a few questions:

1) Are patients more likely to show up for appointments and subsequently receive adequate care when no-show fees are in place?

2) Are the benefits of no-show fees primarily financial for the medical practice?

3) Are there solutions that increase appointment attendance and appointment availability without charging patients fees they may not be able to afford?

4) Moreover, what is the potential impact of no-show fees on patient health outcomes?

These are important questions to consider when evaluating the use of no-show fees in health care.

One of the chief surprises of my search was that there’s remarkably little data on whether no-show fees improve appointment attendance. One 2016 study conducted in King Abdullah University Hospital in Jordan found that introducing no-show fees led to a significant increase in patient attendance. However, it is questionable whether this isolated sample (which took place in a setting with very high starting no-show rates) applies to U.S. populations in 2026. More comprehensive, recent studies are needed to fully understand the impact of no-show fees on patient attendance.

More data was available on the effectiveness of appointment reminders on no-show rates. Several studies like this one have shown significant improvements in clinic attendance through the use of appointment reminders, with text, phone, automated, and manual reminders all significantly reducing no-show rates.

I considered telemedicine as another potential solution to improve the impact of no-show visits, as remote appointments may be more accessible to many patients. One study found that telemedicine visits had, on average, half the no-show rate of in-person visits. Many studies of telemedicine in various specialties found that patient outcomes were equal or better in most fields when telemedicine was offered as an option, with notable exceptions including opioid agonist treatment.

Other findings showed that appointments scheduled more than eight weeks in advance had a higher chance of no-shows, and that high out-of-pocket costs for procedures were another major cause of no-shows.

In a series of patient interviews, patients reported seeing no-show fees as a reasonable measure. However, they were less likely to call ahead to cancel an appointment if they felt disrespected by the practice providing the service. Some patients stated that they felt some medical practices were “so busy, they wouldn’t even notice” a missed appointment. These insights can motivate physicians to prioritize respectful communication, making patients feel valued and understood.

The interviewed patients also voiced a desire for an exception policy for emergency circumstances, such as unexpected illness. This raises another factor to consider: Could no-show fee policies without exceptions encourage patients to bring communicable diseases into the clinic?

At the end of my research, I found that all the following tools improve visit attendance by patients:

1) Robust appointment reminder systems, with text-based reminder systems showing a slight edge over phone call-only systems.

2) Availability of telemedicine, where it is possible, covered by insurance, and not contraindicated for your specialty.

3) No-show fees are applied with clear, upfront communication to patients and with exception policies for emergencies, such as unexpected illnesses. Considering sliding scales for vulnerable patients can foster a sense of fairness and compassion, encouraging physicians to balance operational needs with patient well-being.

No-show fees are just one tool in our arsenal for improving clinic efficiency and enhancing patient care. However, their implementation must be thoughtful and considerate. It’s crucial to balance concerns about patients’ financial well-being with the need to improve patient care. Legally and ethically, physicians must inform patients of no-show fees both verbally and in writing when scheduling appointments, ensuring transparency and respect for patient rights.

However, it’s essential to remember that these policies are not set in stone. Ongoing evaluation and sensitivity to patient populations are crucial to ensure that such policies do not inadvertently create barriers to care. This adaptability ensures that our system remains effective and fair.

Are your no-show policies improving care or creating barriers? Share in the comments.