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.
By Meredith Kirchner, COO and chief client success officer, Curae.
Emergency rooms and specialty care facilities, like infusion and burn centers, serve millions of patients annually in urgent, often life-saving situations.
For many patients, however, these visits are accompanied by steep out-of-pocket expenses they are unprepared for, leaving them with overwhelming medical bills.
At the same time, healthcare systems bear the financial burden of these high-cost care episodes, as nearly 70% of emergency care services can go un- or under-compensated. This dual financial strain places immense pressure on healthcare leaders, who have no choice but to find ways to address both patient affordability and their system’s own financial sustainability.
The Emergency Medical Treatment and Labor Act (EMTLA) plays a significant role in this – enacted in 1986, EMTLA requires emergency departments to screen and stabilize patients regardless of their ability to pay or current insurance status. While this law does ensure access to critical care for all, it prevents physicians from discussing costs or payments until after stabilization. For many patients, this means they are largely unaware of their financial responsibility until the bill arrives, often weeks later.
This dynamic leaves both patients and healthcare systems vulnerable: patients face financial stress that impacts their well-being, while uncollected balances contribute to rising bad debt for health systems.
The impact of increased patient financial responsibility cannot be overstated. With health insurance plans shifting more costs onto patients through higher deductibles and coinsurance, many are left unable to pay their share of medical expenses.
In fact, individuals in the top 10% of healthcare spenders face average annual out-of-pocket costs of over $6,000, while those in the top 1% spend an average of nearly $25,000. Not only do these expenses result in financial stress, but they can also lead to delayed payments and avoidance of future care.
These unpaid balances, combined with the administrative cost of collections, put health systems in a difficult position. Revenue losses from high-cost care episodes limit the ability to reinvest in critical areas like staffing, equipment, and technology, further weakening the organization’s overall financial and operational stability.
Gaining Coverage – Eligible Patients for ACA Plans
Many patients diagnosed with significant diseases and conditions are underinsured or uninsured. A good first step for health systems is to check the patient’s eligibility for an Affordable Care Act (ACA) plan.
Health systems often have service providers and in-house patient advocates perform this work to help complete the enrollment. The coverage in a platinum plan will cover much of the cost of the care (e.g. in-patient stay, infusion therapy and drug cost, oncologist professional fees, etc..), however even if the patient is eligible for an ACA plan and enrolls, there are co-pays and deductibles as with any commercial insurance plan, which could be thousands of dollars for each infusion therapy or procedure.
With or without insurance coverage, patients need medical service financing for out-of-pocket costs over $1,000 and especially for large costs associated with more severe diagnosis and therapies and procedures.
Proactive Financing Programs
Patient financing programs offer a proactive solution to this growing issue. By providing flexible payment options at critical points of care, health systems can reduce the financial strain on patients, improve cash flow, and minimize bad debt. As high-cost care episodes continue to rise, adopting these programs is not just a strategy for maintaining access to care—it’s essential for ensuring the financial resilience of health systems.
In addition, the current economic and regulatory landscape is making patient financing programs more essential than ever. Rising interest rates make traditional payment plans less viable for both patients and health systems, while state laws are increasingly limiting how providers can pursue unpaid medical bills. In fact, many states now prohibit providers from selling patient debt or collecting from low-income individuals, leaving health systems to absorb the cost.
Patient financing programs can provide a compliant, patient-centric alternative that ensures financial stability while avoiding aggressive collection practices. These programs, often managed by third-party institutions, allow patients to cover their expenses over time, reducing immediate financial stress and improving payment adherence. Direct benefits of patient financing programs include:
Improved Access to Payment Options: Patients can pay in manageable installments, reducing financial strain.
Enhanced Financial Stability for Health Systems: Financing minimizes unpaid balances and strengthens cash flow.
Increased Patient Satisfaction and Trust: Providing financial solutions builds confidence and encourages future engagement.
The Role of Technology in Patient Financing
Technology is a critical component of patient financing programs, enabling healthcare systems to manage the process efficiently and with precision. Eligibility for financing can be determined through integration with the electronic health record software (EHR) to provide a seamless workflow for the staff member to provide a financing application quickly to the patient, and then to quickly be able to satisfy the balance with that newly created line of credit.
Once eligibility is determined, these systems provide patients with clear and transparent repayment options. Interactive digital portals or mobile applications allow patients to view, select, and agree to financing terms directly from their devices. Tools like these simplify communication, ensuring patients fully understand their financial responsibilities and repayment timelines as quickly as possible.
The application and enrollment process itself is streamlined through automation, reducing paperwork and manual input. For example, once a patient is approved for financing, the system can automatically generate and process the necessary agreements, set up payment schedules, and send reminders for upcoming payments. Automation not only reduces administrative workloads but also minimizes errors, validates entered information, and therefore improves successful enrollment with speed.
These technologies can also enhance compliance with regulatory standards, such as financial disclosures and data security. Built-in safeguards can ensure that patient financial information is handled according to federal and state regulations, protecting both the patient and the healthcare system.
Looking to the Future
The challenges posed by high-cost care episodes require health systems to rethink how they approach financial engagement. Patient financing programs represent more than just a way to address unpaid balances—they are a means of strengthening trust between patients and healthcare systems. By attempting to alleviate financial stress, these programs may encourage patients to seek necessary care earlier, possibly leading to better outcomes and fewer costly complications.
As we look ahead, patient financing programs are essential to navigating the intersection of patient affordability and organizational sustainability. Systems that embrace these solutions are not just managing today’s financial pressures—they are setting the stage for a more equitable and resilient healthcare system. By prioritizing programs that balance financial stability with compassionate care, health systems can lead the way in creating a future where patients feel supported and organizations remain strong enough to meet the growing demands of their communities.
Patient financing is no longer just a solution for high-cost episodes; it’s a cornerstone of modern healthcare strategy—one that aligns the needs of patients with the priorities of health systems in a way that is both sustainable and forward-thinking.
