Health systems should explore flexible payment plans and focus on pre-service patient engagement to improve revenue cycles, according to a recent PayZen report.
Patients are being asked to take on greater portions of their medical bills at a time when healthcare costs continue to skyrocket. While these diverging trends could spell trouble for revenue cycle managers, they also shed light on opportunities to enhance pre- and post-service collections, mitigate bad debt, and deliver more positive financial experiences for patients.
That’s the takeaway from a new report from PayZen, based on a survey of 213 revenue cycle leaders conducted in partnership with the HFMA. It complements a 2024 PayZen report on healthcare affordability, which was based on a survey of roughly 1,000 patients who had experienced a hospital visit in the previous two years.
High deductibles health plans create an affordability gap
Patient collections are roughly one-quarter of total patient billings, according to the report. One factor influencing patient debt is the increasing prevalence of high-deductible health plans. Just under one-quarter of working-age adults were considered underinsured in 2024, compared with 16% in 2010.
Deductibles vary significantly from one health plan to the next. While the average deductible for employer-sponsored coverage in 2024 was $1,787, average deductibles for marketplace plans ranged from $1,430 for a gold plan to $7,258 for a bronze plan.
With roughly one-half of Americans living paycheck-to-paycheck, amounts owed by patients with high-deductible health plans is often out of reach.
Strategies to address unpaid balances, bad debt
“Hospitals don’t want to be in the business of lending, yet many are left with little choice,” Tobias Mezger, chief revenue officer at PayZen, said in a statement.
Buy Now, Pay Later (BNPL) financing services offered in retail settings could serve as a model for health systems looking to reverse rising levels of unpaid balances and bad debt, according to PayZen. Roughly 40% of American adults use at least one BNPL service, and the market is expected to exceed $122 billion in 2025.
Most health systems already offer in-house payment plans, but these could benefit by allowing additional flexibility to patients or through partnerships with third-party financing partners.
The average patient can only pay $97 per month for medical expenses, while 21% can only afford up to $15 to $30 per month, according to the report. This means that, for the average patient, a 12-month payment plan would only be affordable for medical bills up to $1,200, and 24-month plans would only be affordable up to amounts of $2,350. These figures are well below the amounts many patients could potentially owe under high-deductible health plans.
Despite this math, 58% of health systems cap payment plans at 24 months and 28% cap payment plans at 12 months. An additional 7% do not offer in-house payment plans at all.
Three-quarters of patients shared that they would be more likely to pay their healthcare bills over extended periods of time, according to PayZen.
Alternatively, improving pre-service collections can have a significant positive impact on financial stability, according to the report. Health systems that require or encourage pre-service payments, or require a payment method on file, have a 20% higher overall collection rate.
During a recent HealthLeaders Revenue Cycle NOW Online Summit event, Shannon Ducat, associate vice president of patient access at ProMedica, said her health system has seen an increase in pre-service collections since implementing new scheduling processes that included the creation of a pre-registration team.
Before selecting a vendor to aid in prior authorization management, health systems should conduct their own "needs assesment," according to Christine Migliaro, VP of front-end revenue cycle operations for physician partners at Northwell Health.
Prior authorizations are an increasingly significant challenge for revenue cycle leaders. Technology vendors offer solutions to ease the process and reduce payer-provider friction, but there can also be a tendency to overpromise and underdeliver.
In this episode of HL Shorts, Christine Migliaro, vice president of front-end revenue cycle operations for physician partners at Northwell Health, shares her tips for success in the vendor selection process.
Revenue cycle leaders from ProMedica and University Health Kansas City joined HealthLeaders for a candid talk on their strategies for improving patient engagement.
Health systems are being forced to rethink patient engagement whether they like it or not. Patients are demanding more consumer-friendly, tech-based tools, while government regulations like the No Surprises Act require more transparency around prices. What strategies are revenue cycle leaders exploring to improve patient engagement without sacrificing operational efficiency?
“Patients want their healthcare experience to be as seamless and as convenient as online shopping and online banking,” Ducat said. “So, for strategic initiatives, we’re focused on expanding those self-service tools.”
One patient engagement initiative at ProMedica established automated workflows that give patients greater control over scheduling.
Less than two years ago, the centralized scheduling team at ProMedica was a wholly outbound operation. It felt like the team was chasing patients, often calling while they were at work or otherwise unavailable, Ducat said.
Today, ProMedica is using technology to automatically call and text patients the day after a provider places an order.
Patients have the option of connecting at that time, or at a future time of their choosing. They also receive self-registration links and cost estimates via online portal ahead of their visits. The automated system makes five attempts to contact patients over 90 days.
“We kind of turned our scheduling center around and went from a completely outbound call center to a completely inbound call center,” Ducat said.
At University Health Kansas City, investments in new payment systems mean patients now have additional payment options, like Apple Pay and Google Pay. The academic medical center has also invested in technology to enable accurate cost estimates.
Investing in consumer-friendly digital tools and in-demand tech goes beyond meeting regulations like those in the No Surprises Act, however.
“It’s a key strategy to grow and to retain your patients,” Katz said. “Hospitals that don’t lean into that mode and that idea are going to be left.”
Benefits to patient engagement initiatives outweigh drawbacks
As part of its patient access redesign, ProMedica established a fully remote pre-registration team that calls patients five to ten days before their appointments to complete most tasks typically done day-of-service.
While the approach streamlines patient visits, there has been some resistance to the change. For instance, patients used to traditional patient access models may be reluctant to share personal health or payment information over the phone.
“It’s something new,” Ducat said. “I think some patients have a little bit of a trust issue with just the legitimacy of the phone call.”
Of course, resistance to change also comes from internal sources. While many clinicians are excited about the potential to improve patient engagement, some prefer the level of control afforded to them in under traditional models.
The success of patient engagement initiatives depends on buy-in from senior leadership and from physicians.
“It is a culture shift,” Katz said. “That can be a challenge for some organizations or for some people within those organizations.”
While resistance has been a challenge, the benefits to these patient engagement initiatives can’t be denied.
Since implementing new scheduling and pre-registration processes, ProMedica has seen a decrease in eligibility denials and an increase in pre-service collections.
Similarly, University Health Kansas City has been able to improve the accuracy of the data it collects since providing patients with more tools to update their information via online portals and self-serve kiosks. This has reduced friction in the prior authorization process.
“Everything that happens up front has major implications through the rest of your revenue cycle,” Katz said.
A recent Executive Order takes aim at drug pricing, with significant implications for the 340B Drug Pricing Program.
The Trump administration recently issued an Executive Order directing federal agencies to take steps to reduce prescription drug prices. Among the wide-ranging directives are two provisions that would significantly impact the 340B Drug Pricing Program.
One provision would require provider organizations participating in the 340B program to make insulin and injectable epinephrine available at or below the discounted price that they paid for the drugs.
The other provision instructs the Department of Health and Human Services (HHS) to gather data on hospital acquisition costs for outpatient drugs and to propose reimbursement adjustments that align Medicare payment with acquisition costs.
Recent controversy surrounding the 340B program
The 340B program, established in 1992, requires drugmakers to provide outpatient drugs at discounted rates to eligible provider organizations. The program is intended to free up money for hospitals to use elsewhere in ways that support low-income and other underserved patients.
The 340B program has been mired in controversy for the past several years, but multiple revenue cycle leaders have said the discounted rates through the 340B program are essential to their organizations’ financial health.
“Henry Ford Health system and a lot of folks rely on 340B discounts and other mechanisms like disproportionate share payments,” Robin Damschroder, the health system’s CFO, told HealthLeaders in a 2022 interview. “We're a big teaching institution, so a lot of these special payments that we do in order to teach the healthcare leaders of the future or make sure that we can take care of vulnerable patients are extremely important.”
“340B going away would not only be devastating for us but incredibly devastating to our patients because it does fund some other things that we can do in our organization to serve that indigent population,” added Cheryl Sadro, former CFO for UC Davis Health and current CFO for John Hopkins Medicine, told HealthLeaders in a separate 2022 interview.
On the other hand, critics say that the 340B program lacks transparency and that participating provider organizations frequently fail to use savings on the populations that the program is intended to help.
This criticism prompted the formation of a bipartisan group of legislators to explore changes to the 340B program. The Senate 340B working group released a legislative discussion draft last year.
“The 340B drug pricing program is not working as effectively as it should,” Senator Jerry Moran (R-Kansas) said at the time of the group’s formation. “The confusion around its contract pharmacy provisions and lack of transparency and congressional oversight is failing the patients the program exists to help.”
The Supreme Court offered some 340B relief – for now
In 2018, the Centers for Medicare & Medicaid Services (CMS) reduced payment rates for 340B drugs to average sales price minus 22.5%, stating that the formula would more accurately account for actual costs incurred by 340B hospitals.
However, the Supreme Court ruled against these rates in 2022, saying that HHS had not properly surveyed hospitals’ acquisition costs. The decision led to a $9 billion remedy payment for eligible hospitals in 2023.
Healthcare leaders were pleased at the time. However, scrutiny over the 340B is still strong, and both Congress and the White House seem eager to make adjustments to the program. Revenue cycle leaders would be wise to keep contingency plans in their pockets.
Revenue cycle leaders today are tasked with improving patient engagement, while they're facing frustrating prior authorization requirements that lead to skyrocketing denial rates.
Health systems are under pressure to meet patient demands for more consumer-friendly experiences while wrestling with increasingly stringent prior authorization requirements. How are revenue cycle leaders balancing these dual priorities?
This Wednesday, revenue cycle leaders will share their tips for improving patient engagement and strategizing around prior authorizations during the HealthLeaders Revenue Cycle NOW event.
The event is split into two separate webinars:
How to Improve Patient Engagement in Today’s Healthcare Revenue Cycle (10-11 a.m. EDT)
Effective patient engagement is critical to revenue cycle management. However, patients are growing frustrated with a consumer experience that frequently fails to deliver the digital tools and pricing transparency offered by other industries. Some RCM leaders have rethought their approach to deliver both a better experience and improved operational efficiency.
In the opening session, sponsored by Waystar, Shannon Ducat, associate vice president of patient access at ProMedica Health, will join Seth Katz, vice president of revenue cycle and HIM at University Health Kansas City, to discuss the steps they are taking and strategies they are using to reduce patient uncertainty, minimize denials, and decrease friction between patients, providers, and payers.
Revolutionizing Revenue: Technology and Strategic Solutions for Prior Authorization (11:10 a.m.-12:10 p.m. EDT)
Prior authorizations are an ever-present headache for revenue cycle leaders. Unclear prior authorization requirements and shifting payer policies have contributed to skyrocketing claim denial rates, impacting the financial health of hospitals across the country. To help ease the pain, healthcare leadership is exploring new automation technologies and changing the way they interact with payers.
In this session, sponsored by Optum, Christine Migliaro, vice president of front-end revenue cycle operations at Northwell Health, and Savanah Arcenaux, director of pre-service and financial clearance at Ochsner Health, will share the solutions they are exploring to reduce the prior authorization burden.
Interested in joining the webinars? You can register here.
Growth in Medicare Advantage enrollment has slowed and plans are performing more poorly in quality ratings than in other recent years, according to a recent report.
After several years of rapid expansion, enrollment in Medicare Advantage has slowed in 2025, according to a recent report from Chartis. A majority of new beneficiaries have opted for plans administered by for-proft payers. Overall, about three-quarters of MA beneficiaries are in plans run by for-profit payers while the rest are split between non-profit Blue plans, other non-profit plans, and provider-sponsored plans.
Check out more numbers from the report below, or read HealthLeader's full coverage.
Medicare Advantage enrollment grew at 3.9% last year despite market conditions unfavorable to payers.
Medicare Advantage (MA) enrollment has slowed following a period of rapid growth in the early 2020s.
MA plans added 1.3 million new members since 2024, an increase of 3.9% year-over-year, according to a recent report from Chartis. Meanwhile, traditional Medicare added 200,000 members.
Revenue cycle leaders may be pleased with slowed growth, as many provider organizations have become increasingly frustrated with the commercial payers administering MA plans.
MA enrollment by the numbers
Growth in MA peaked earlier this decade when enrollment grew at rates of 7% to 10%, according to Chartis. While enrollment in traditional Medicare ticked up for the first time since 2020, there are now more members enrolled in MA plans than in traditional Medicare.
In 2020, 60% of all Medicare beneficiaries were enrolled in traditional Medicare vs. 40% in MA. Now, 49% are enrolled in traditional Medicare vs. 51% in MA.
The majority (55%) of new MA beneficiaries are enrolled in for-profit plans. Overall, around three-fourths of MA beneficiaries are enrolled in plans from for-profit payers.
However, the growth rate in non-profit plans exceeded typical rates of about 15% seen earlier in the decade. Provider-sponsored health plans account for 8% of all MA beneficiaries in 2025, compared with 11% in 2020.
Market conditions challenge payers
Market conditions – including rising utilization, lower-than-expected rate increases, and increased regulatory scrutiny – have led some payers to slow growth in or, in some instances, exit MA markets. For instance, Premera and Blue Cross Blue Shield of Kansas City both exited the MA market. Others, like Aetna and Humana, reduced service areas and terminated plans.
Payers offered fewer MA plans than they had in the previous year. The total number of MA plans available grew from 4,284 in 2020 to 5,673 in 2024 before falling to 5,581 in 2025. Additionally, more than 60% of plans weakened benefit offerings.
Quality rating performance among MA plans also fell from the previous year. Around 80 % of MA beneficiaries were in plans rated 4stars or above by the Centers for Medicare & Medicaid Services (CMS) in 2024 vs. 64% in 2025.
How MA impacts rev cycle leaders
MA plans pose significant challenges for revenue cycle leaders, adding layers of administrative complexity to overburdened workforces.
Prior authorization requirements, which are rarely used in traditional Medicare, have become a difficult-to-navigate feature of many MA plans, leading to denials and lost revenue. One analysis showed that claim denial rates fell in traditional Medicare from 2023 to 2024 while they rose 4.8% for MA plans.
Cost-sharing arrangements between patients and their plans often leave patients on the hook for services that are not covered.
Rachelle Schultz, Winona Health president and CEO, recently told HealthLeaders that she has “heard so much feedback from patients who felt like they got blindsided by what was covered, what was not covered.”
Prior authorization legislation, which is on the table, could help relieve some of the administrative burden that MA plans lay on revenue cycle leaders. However, in the meantime, slowed MA growth could provide revenue cycle leaders with some clarity regarding payer mix in the future, which could better inform their revenue cycle operations.
The House of Representatives is considering legislation that would reform the way payers use prior authorization. Which payers would the bill affect and how?
A bipartisan group of legislators, led by Rep. Mark Green, MD (R-Tennessee) introduced the Reducing Medically Unnecessary Delays in Care Act of 2025 legislation in the House of Representatives last month.
The bill would affect payers participating in federal health programs and transform the way that they are allowed to use prior authorization to deny claims.
Check out the infographic below to learn more about the bill, or read HealthLeaders' earlier coverage here.
A bipartisan group of physician legislators has introduced legislation in the House of Representatives to reform payer use of prior authorization.
Congress is considering a bill that would place new restrictions on prior authorization (PA) for payers participating in federal health programs.
Rep. Mark Green, MD (R-Tennessee) introduced the Reducing Medically Unnecessary Delays in Care Act of 2025 legislation in the House of Representatives last month.
Co-sponsored by, among others, GOP Doctor Caucus Co-Chair Greg Murphy, MD (R-North Carolina) and Democratic Doctors Caucus Co-Chair Kim Shrier, MD (D-Washington), the bill would require physician review of PA denials and increased transparency from payers regarding PA criteria and denial rates.
What would the bill do?
A key component to the bill, which would apply to all Medicare Administrative Contractor (MAC), Medicare Advantage, and Part D prescription drug plans, would require PAs and adverse determinations be made by licensed, board-certified physicians.
The bill would also require impacted plans to establish and to publish online clinical criteria for PA requirements. These criteria would need to align with current evidence-based standards, and payers would need to evaluate and update PA requirements at least once per year.
For services without accepted evidence-based standards, the lack of standards would be insufficient to deny coverage.
The intent behind the bill is to give providers more control over care decisions and reduce the administrative burden on provider organizations, according to lawmakers. According to American Medical Association (AMA) data, physicians and their staff are spending an average of 16 hours per week on PA-associated tasks.
There is also growing concern over the use of AI by payers in PAs.
“Doctors need to be able to make fast, life-saving decisions without a jungle of red tape to cut through,” Green said in the press release.
“No one should lose out on medical care because an AI algorithm is challenging what a doctor has already deemed a necessity,” Schier added in the press release. “As a physician myself, I've seen firsthand how prior authorization has created life threatening barriers to essential and standard care.”
What are RCM executives saying?
Revenue cycle leaders and their clinician colleagues have seen claim denial rates explode over the past several years, and they’ll likely welcome any legislation that aims to streamline PA approvals.
“Often, prior authorization requests are reviewed—and denied—by insurance company representatives who lack the medical expertise to appropriately judge what level of care is necessary for a patient,” AMA President Bruce Scott, MD, said in a statement.
While revenue cycle leaders are eager for laws that simplify their workflows, they should be wary of unintended consequences.
Ambiguous language in the bill could hamper the pursuit for increased efficiency, according to Josh Mandel, MD, chief architect for Microsoft Health.
“This ambiguity creates significant risk,” he wrote in a recent post on LinkedIn. “Mandating physician review for every routine approval would drastically increase costs, introduce potentially massive delays for necessary care (ironically contradicting the proposal's title), and could disincentivize the use of PA altogether, possibly leading to broader utilization controls elsewhere.”
Beyond the bill
Green introduced similar legislation in 2022 and 2023, and it remains to be seen whether the third time is a charm. However, this effort is part of a larger trend among lawmakers to target payers’ claim denial practices.
At least 10 states passed laws in 2024 to create new rules around prior authorization requirements. Some states have new laws going into effect in 2025, while others have kicked off their 2025 legislative sessions with new proposals.
Of course, legislative processes are not known for their fast pace. For revenue cycle leaders who want to get off the sidelines and onto the playing field, consider these tips from Amanda Bessicks, executive director of government and vendor relations at Baptist Health in Northeast Florida, for working with your organization’s government relations team.
A new RAND report finds that reimbursement for Emergency Department services is declining, and emergency care could be at risk unless changes are made.
Emergency departments (ED) are crucial components of the healthcare system, playing a significant role in public health, providing around-the-clock access to timely care, and delivering services regardless of a patient’s ability to pay. But a new report questions their future unless changes are made.
Despite their importance, EDs face numerous challenges that threaten their ongoing sustainability, according to the recent RAND report, funded by the Emergency Medicine Policy Institute (EMPI).
The results offer useful insights for revenue cycle leaders tasked with monitoring cash flows while balancing legal obligations for patient access and billing under laws like EMTALA and the No Surprises Act.
However, while healthcare leadership can continue to pursue best practices and emerging technologies to achieve efficiencies that boost patient payment rates and reduce friction in claims processing, RAND researchers suggest the viability of emergency care is at risk unless policymakers take action on multiple fronts.
High demand and insufficient capacity
ED visits, which declined during the height of the COVID-19 pandemic, have returned to near pre-pandemic levels.
While the current volume is not unprecedented, EDs are being asked to do more with the patients they tend to, according to RAND. Many of these patients – including the elderly, unhoused individuals, and undocumented immigrants – come from populations with complex medical and social needs.
Increases in demand for ED services, combined with increases in patient complexity and acuity, have resulted in overcrowding that weighs on both patient satisfaction and provider stress levels.
Lower pay for more work
While their scope of work has expanded, payments to ED physicians have fallen, according to RAND.
After adjusting for inflation, Medicare and Medicaid paid 3.8% less per ED visit from 2018 to 2022. Payments for commercially insured patients have dropped even more significantly – by 10.9% for in-network visits and 47.7% for out-of-network visits over the same time period.
ED providers interviewed by RAND researchers expressed significant concern over existing fee-for-service payment models, which they say increasingly fails to compensate EDs for the services they provide. Around 20% of all ED physician expected payments are unpaid across all payer type, according to RAND. This amounts to roughly $6 billion per year in unpaid ED physician services.
The negative impact of the No Surprises Act
Enacted in 2022, the No Surprises Act (NSA) protects patients from receiving surprise bills when they receive out-of-network emergency care at in-network facilities. While intended to help patients, many ED providers argue that the new law gives too much power to payers in contract negotiations.
“The NSA is probably the biggest threat to us right now,” one provider told RAND researchers. “It takes away any leverage that we have to negotiate with payers.”
Additionally, the NSA established a process to facilitate disagreements over payment amounts between payers and providers. However, this process has added another layer of administrative complexity for EDs and caused delays in reimbursement.
Hope on the horizon?
RAND researchers propose several policy prescriptions to help relieve EDs of financial strains:
The American College of Emergency Physicians (ACEP), healthcare organizations, and other stakeholders should advocate funding for the EMTALA mandate, which guarantees access to emergency care regardless of an individual’s ability to pay.
Local governments and other stakeholders should pursue policies to allocate city and local funds to ED care and related activities that confer value to the broader community, such as care for substance use disorders and mental health conditions.
ACEP, healthcare organizations, and other stakeholders should develop uninsured and underinsured patient compensation benchmarks so that EDs are compensated commensurate with the level of indigent care they provide.
Healthcare organizations and legislatures should invest in expanding primary care capacity and develop and implement strategies to address ED crowding.
Legislatures should institute state or federal laws that protect healthcare workers by increasing the legal consequences for violence against healthcare workers.
ACEP, patient advocacy groups, and other stakeholders should advocate Medicaid expansion in states that have not adopted it yet and should advocate Medicaid parity with Medicare; and
Legislatures should require payers, rather than emergency care professionals or hospitals, to collect deductibles and copays from their enrollees and should implement a legislative fix to No Surprises Act flaws so that payers must pay in full any independent dispute resolution judgments to the prevailing physicians within a preset time frame.
Of course, these solutions require lawmakers to act. In the meantime, revenue cycle leaders should continue to utilize the dispute resolution process under the NSA while working with facility partners to stabilize practice revenue and cash flow, according to Patrick Velliky, senior vice president of government affairs for Envision Health and chairperson of the EMPI board of governors.
“ED physicians already face high levels of burnout as a result of being asked to do more with less,” Velliky wrote in an email to HealthLeaders. “Both organizational and public policy must consider the impact of increasing acuity and declining reimbursement on the well-being of physicians and their patients.”
