You can make walk-ins work

August 17, 2007

Patients who come in without appointments can disrupt-or build up-your practice. A solid walk-in policy will make the difference.

Key Points

Charles Davant III, a family physician in Blowing Rock, NC, recently returned from a Baltic Sea cruise-paid for by walk-ins, he says. "In my three-physician practice, we take care of anyone who wants to be seen that day, provided they're willing to see whichever of us has an opening, and provided they're willing to wait."

Conversely, East Orange, NJ, cardiologist Shashi Agarwal views walk-ins with suspicion, stemming from "25 years of poor experience with this population." People who see a cardiologist without a prior call or referral, Agarwal says, "either are drug addicts who claim that they're new to the area or their doctor has moved away, gone on vacation, or died; or patients who present with expired insurance cards or pay with checks that never clear. And, of course, our schedule is disrupted by walk-ins regardless of their motivation and insurance status."

Love 'em or hate 'em, walk-ins are a fact of life in office-based medicine, so rules to deal with them are essential. Walk-in policies will vary from practice to practice, and even from physician to physician within a practice, depending on who's on call, who's looking for a heftier patient roster, and what sort of help the unannounced patients need.

Even if you accommodate people who show up at the front desk without a call or an appointment, you don't have to see every one of them. Jeffrey J. Denning, a practice management consultant with Practice Performance Group in La Jolla, CA, recommends that walk-ins get the same screening telephone callers do: Question them to determine whether their problem meets your emergent (see today) or your nonemergent (not today, but this week) criteria.

"Of course, true emergencies need to be addressed right away," says Denning. "But in the case of lesser emergent problems, the front-office staff can tell the patient you'll see him as soon as there's a break in your schedule. Or-better yet-the patient can be instructed to return at the end of the day to avoid wrecking on-time performance for scheduled patients."

Handling walk-ins will go more smoothly if you do your homework. Keep a running tally of how many patients show up with emergent and nonemergent problems, and adjust your schedule accordingly, says Denning. For example, if your practice usually gets two walk-ins with emergent problems on a Monday, save two slots on every Monday's schedule, to be handed out only that day-perhaps one in the late morning and one in the afternoon. Estimate how many nonemergent slots you need, too, so if a patient walks in on Monday with a problem that can wait, you can offer him an appointment later in the week.

In a group practice, who sees walk-ins? It could be a PA or an NP, or a "designated walk-in provider" (usually that day's on-call physician). At FP Sumana Reddy's five-provider practice in Salinas, CA, walk-ins are assigned to anyone who has an opening. "We've found this to be a great way to build the newest clinician's practice, since walk-in patients are more willing to see whoever is available, and to tolerate long waits," Reddy says.

Kenneth T. Hertz, a Medical Group Management Association senior consultant based in Alexandria, LA, worked with an orthopedic practice that funneled all walk-ins to an older physician who no longer did surgery. He, in turn, triaged those patients to the appropriate physician. "This helped accelerate access to the practice, and ensured that the 'operating' orthopedists saw a higher percentage of surgery candidates," says Hertz.

Solo practitioners need a walk-in policy that addresses the challenges of going it alone. In Taunton, MA, pediatrician Eric J. Ruby's practice, for instance:

"We set aside 10 minutes each hour for 'catch up,' and flexibility is the watchword," Ruby says.

"Physicians often use the term 'walk-in' as a pejorative, but that needn't be the case if you're set up to handle patients who don't call ahead," says Judy Bee, Jeff Denning's colleague at Practice Performance Group. Some of them are teens and 20-somethings who've never developed a relationship with a physician and would make excellent additions to your patient base.

Educating patients, and getting paid

Once word gets out that your practice is walk-in friendly, you'll need to establish ground rules to keep walk-in traffic from compromising your daily schedule. Stefan Topolski, an FP in Shelburne Falls, MA, limits walk-ins to five-minute slots, with waits of up to two hours. "We do a little acute triage, then give them a follow-up appointment if medically necessary," he says.

Your walk-in policy should distinguish between new and established patients. In her solo practice in Mullins, SC, family physician Rosanne Hooks arranges her schedule so she can see walk-ins within 30 minutes-if they're already on her patient roster. If she's never seen the patient before, however, her husband and office manger, Wayne Hooks, contacts the patient's previous physician to get basic information faxed over.

Depending on your specialty, you might find it appropriate to see walk-ins under specific circumstances, which you determine and enforce. Sharon Packer, a psychiatrist in New York City, urges patients to call first "because the rest of the world expects people to schedule appointments, and I'd be reinforcing inappropriate behavior if I encouraged this practice." Occasionally, however, a college student's parents come by without notice at the time of the student's appointment. "With the patient's approval, I welcome them in for a moment, shake their hands, and apologize that I don't have more time to spend with the entire family that morning," Packer says. "I offer to schedule a family appointment at another time, but I've never had anyone take me up on it. I sense that families just want to see the psychiatrist who's treating their college-age kids."

FP Omar A. Khan discourages what he calls "show up when you feel like it" patients at his practice in Wilmington, DE, because, as he notes, same-day appointments are almost always offered to those who call that day. "The point is not to have a crowded waiting room," he adds, "as well as not to give pre-set patients the sense that a walk-in has taken their slot." Likewise, Michael Casser, a pulmonologist in Englewood, NJ, sees walk-ins because "turning them away is not a good ethical or business decision." But he encourages them to call first the next time because "that's usually less costly for them, and it means a shorter in-office wait."

Speaking of costs, your walk-in policy should include mechanisms to ensure that you'll get paid. Staffers at Sumana Reddy's practice noticed that patients who were in arrears would drop by in the hope of being seen before anyone noticed the red ink on their account. To avoid this, tell your employees to verify walk-ins' account status and review their insurance coverage. If you suspect that walk-ins are trying to slip under your payment surveillance radar, ask for full payment up front, with the promise that you'll refund any money you receive from third-party payers.

Enforcing an appointment-only policy

In FP Mike Christian's view, shoehorning walk-ins into a busy schedule isn't good for physicians or patients. "Everyone gets shortchanged," says Christian, who practices in Moses Lake, WA. "You can't justify missing something by saying you rushed because of a walk-in."

If you prefer to keep walk-ins at bay, make sure you're not subtly encouraging them, says Judy Bee. For example, how difficult is it for patients to get through to your office on the telephone? "Many walk-ins I've talked to simply grew tired of getting a busy signal or being put on hold," Bee notes. "Or the word might be out that on days when patients are told you're booked solid, those who show up unannounced are seen anyway."

If you want to limit or put an end to walk-in traffic, how do you discourage these patients without offending them or, worse, putting them and the practice at risk? Judy Capko, a consultant in Thousand Oaks, CA, recommends giving receptionists a "cheat sheet" listing presenting symptoms that should be reported to you or another clinician immediately.

Judy Bee stresses diplomacy, recalling a young FP who purchased a practice close to the Mexican border, where patients were used to showing up early in the morning and waiting to be seen. Little by little, the new doctor had his staff give patients appointments-either later that day or a few days hence-and ask them to return then. Those who continued to drop in were told, "It's a shame you didn't call first. Dr. Jones is fully committed today but can see you at 3 on Wednesday. Will that work for you?"

A not-so-subtle means of dissuading walk-ins is to tell them they'll be seen only if they pay a surcharge, as Scott Katz, a pediatrician in Plano, TX, does. "It's not intended to make a lot of money," he says. "Rather, it's to enable our office to run on time for the patients who had the courtesy to call ahead. It also applies to parents who make an appointment for one child, arrive at the office, and want us to see a second child." But Katz usually waives the surcharge if the child who's unscheduled is seriously ill.

Sometimes, no matter what you do, the walk-ins keep on coming, especially in pediatrics, where panicky parents rush children to the doctor for matters that turn out to be minor. "When we tried to be strict with parents, they complained that they came by because they couldn't get through to us on the telephone. If we tried rescheduling them, they went to the ED or another office, and we never saw them again," says Alberto Kriger, a pediatrician in Pembroke Pines, FL. "Even though it's sometimes disruptive to the flow of patients, we now just accommodate walk-ins."

"Usually," says Jeff Denning, "it's a matter of letting physicians have the practices they want and giving staff the tools they need to do a good patient service job."

Is that walk-in patient a drug seeker?

No one knows how many patients who show up at physicians' offices without appointments are looking to score their drug of choice, but some undoubtedly are, so it's wise to be vigilant.

What are some red flags to watch for?

New York City psychiatrist Sharon Packer is wary of patients who say their regular physician is on vacation-or say they're looking for a new psychiatrist but can't give a good reason for wanting to change doctors. Or they might claim that their last Xanax prescription was written in another state but they can't remember the name of the prescribing physician and just need an "emergency" refill.

"In psychiatry, many walk-ins are drug seekers who've been axed by their prior prescriber or who have used up their pills and are looking for a fresh start," says Packer.

Wayne Hooks, the office manager for his wife Rosanne Hooks' family practice in Mullins, SC, says that drug seekers often give themselves away. A 19-year-old requests OxyContin for excruciating back pain, for instance, but is vague about the trauma or condition that caused the pain and hasn't seen a physician in years. If Hooks suspects that a walk-in is there solely for drugs, he'll tell the patient that the doctor will be glad to see him but won't prescribe controlled substances without medical evidence-a note from another physician or an MRI report, for example-that such drugs are needed. "That's when they usually head for the exit," says Hooks.