Electronic Health Reporter

By Matt Fisher, VP of Operations, Curae; president, HFMA Georgia.

The next revenue cycle risk for health systems may not arrive as a denied claim or an unpaid statement. It may first appear as work that is harder to see, such as a missed health insurance premium renewal,  a patient who can no longer afford their marketplace or employer-sponsored health plan , or an out-of-pocket responsibility that exceeds what the patient can realistically pay.

That hidden work matters because it reaches the revenue cycle before a balance ever ages. Coverage and affordability issues often begin upstream during scheduling, when staff are verifying coverage, determining expected out-of-pocket costs, and discussing financial options with patients. By the time an account reaches the back end, the balance may have originated weeks earlier due to an enrollment issue, an affordability challenge, or a patient who did not understand their financial responsibility.

Medicaid, the Affordable Care Act, and broader affordability changes are creating a continuous cycle of coverage disruption that will play out over the next two years. Each policy shift creates another point where patients can lose coverage, misunderstand their benefits, or face costs they cannot realistically afford. ACA premiums were projected to rise by a median 15% in 2026, based on a KFF analysis of preliminary filings across 19 states and Washington, D.C.

New Medicaid work requirements will also require some enrollees to document 80 hours of work or qualifying activities each month, creating another point where eligible patients may lose coverage because of administrative barriers rather than a lack of need for care. For many of those patients, the challenge does not end with losing Medicaid. Transitioning to Marketplace coverage may mean facing premiums they cannot afford, creating a separate affordability issue where strategies such as premium sponsorship can help eligible patients maintain coverage and access to care.

CFOs and revenue cycle leaders need a fuller view of coverage risk than a yes-or-no insurance check can provide. A patient may have coverage at registration but still be at risk of losing it, misunderstanding it, or facing a balance that will move quickly into bad debt. Patients may remain insured while still being unable to afford care because of rising deductibles, premium contributions, or cost-sharing requirements, creating the rise of the “insured but unaffordable” patient.

Eligibility Friction is Becoming a Cash Flow Problem

Eligibility friction creates work across health systems long before an account reaches collections. Outdated coverage can affect registration, missing documentation can lead to denials, and a plan change can leave patients confused by an unexpected deductible. Patient collections teams may eventually receive balances that would have been better routed earlier to financial assistance, charity care, enrollment support, or a medical payment plan.

The downstream risk is larger because many households have little room to absorb medical bills. Medical collections accounted for 57% of all collections tradelines on consumer credit reports from 2018 to 2022, according to the Consumer Financial Protection Bureau. Once a balance reaches collections, the health system has usually lost the best chance to preserve coverage, recover a claim, or match the patient with an appropriate payment path.

Patient Access Needs Earlier Financial Signals

A cleaner front-end process can prevent some accounts from taking the long route through denials, statements, and collections. Eligibility data, prior balances, high-deductible exposure, and propensity to pay can help revenue cycle teams identify when a patient may need support before the bill is finalized.

That support will not look the same for every account. A patient coming off Medicaid may need help with enrollment or marketplace guidance. A patient with a correctable coverage issue may need a claims review before the balance shifts to patient responsibility. A patient with a valid balance may need health service financing, an interest-free medical loan, a medical line of credit, or a medical payment plan that fits the household’s actual budget.

With the right financial context, patient access can help identify risk earlier and direct patients toward enrollment help, financial assistance, or a payment option before the account moves further downstream.

Financing Should Fit the Patient’s Situation

Patient financing programs will become more important as coverage instability leaves more patients with larger balances, but financing works best when it follows a clear review of the account. Health systems first need to determine whether the patient has an eligibility issue, a claim issue, a financial assistance need, or a true patient responsibility balance. When financing is appropriate, options may include shorter-term in-house payment arrangements for smaller balances and longer-term zero-interest financing for larger patient responsibilities, depending on the organization’s approach and the patient’s financial situation.

When financing is appropriate, revenue cycle leaders should evaluate patient financing companies and services based on access, compliance, patient clarity, and provider risk. The best options should be accessible to patients with limited savings, provide funds quickly, comply with consumer credit requirements, and support a positive patient financial experience. Programs built mainly around high-credit patients may improve the patient financial experience for a narrow group, but they will not address many of the balances most likely to become bad debt.

Non-recourse patient financing may be part of the evaluation because it can reduce provider exposure if the patient does not repay. Healthcare payment technology should also connect financing to patient access, billing, and follow-up, ensuring payment options fit into the broader financial access process.

Health Systems Need a Two-Year Operating Plan

The next two years are likely to bring repeated coverage changes rather than one clean disruption. Health systems will need a way to catch coverage issues early enough to keep patients from drifting into avoidable balances.

That work will affect healthcare finances well beyond collections. A missed renewal or unaffordable plan can change payer mix, strain cash flow, and increase uncompensated care before the account ever reaches the back end. Pushing harder on collections may recover some balances, but health systems cannot collect their way out of growing coverage instability and affordability challenges. The larger opportunity is identifying financial risk earlier, preserving coverage whenever possible, and connecting patients with the resources they need before balances become bad debt.

Health systems that prepare now will be better positioned to protect margins while helping patients maintain access to care. As coverage disruption continues over the next two years, organizations that treat financial access as an ongoing operational function, not simply a collections function, will create better outcomes for both their organizations and the patients they serve.