Pre-service patient payments become a strategic priority for health systems

Improving pre-service payments and the patient financial experience is becoming a strategic priority for hospitals and health systems as patients shoulder more of the cost of care.

The shift is reflected in PayZen’s second annual State of Healthcare Affordability: The Provider Perspective 2026, based on a survey of more than 200 health system revenue cycle leaders conducted by HFMA in partnership with PayZen.

• Although commercial revenue remains most health systems’ primary focus, patient balances are a growing concern. Nearly all respondents ranked patient balances as a top concern, with about one out of five (21.9%) identifying it as their highest priority in the 2026 survey, up from 11.4% in 2025.
• Increasingly, health systems are seeking to improve early engagement with patients related to their expected out-of-pocket amount due. In the 2026 survey, 91.5% of respondents reported encouraging or requiring upfront payment or collecting a payment method on file, up from 81.3% in 2025.
• The patient financial experience is becoming a higher-priority focus, with 41.3% of respondents listing it as among their top priorities in the 2026 survey, up from 18.5% in 2025.

In this HFMA Executive Roundtable, eight patient financial services leaders share how they are working to strengthen both patient collections and the patient financial experience.

If you could redesign your patient payment strategy from scratch, what would you do?

Nicholas Bilas: We are fundamentally rethinking the patient financial experience by moving financial engagement upstream, creating more opportunities to educate patients and resolve financial questions before care is delivered. The objective is to shift as much of the financial responsibility conversation as possible to the pre-service phase, where patients have the time and clarity to make informed decisions. That requires a dedicated team capable of explaining cost estimates, demystifying insurance coverage and helping patients understand their expected financial responsibility. Equally important is delivering that guidance through a centralized point of contact at the right moment in the patient journey, whether during scheduling or the initial pre-service consultation, so every patient receives a consistent, transparent and supportive experience before they arrive for care.

Preston Hodapp: We’re also redesigning a lot of little things to be more patient friendly. We want our MyChart set up so patients can do everything there that they can with a phone call. We want bills to have a scannable QR code for answers to common questions. We are working on TikTok clips to explain terms like EOB (explanation of benefits), deductible and out-of-pocket maximum. We are looking at how to offer prompt-pay discounts for pre-service to increase the incentive. Right now, prompt-pay is only available once there’s a bill.

Nikki Harper: We recently redesigned our patient financial experience. We looked at patient populations by the services they’re coming in for and what that means for the patient financial experience they want. Higher-acuity patients, like transplant patients, who come in for multiple visits across outpatient and inpatient care need a very different patient financial experience than an outpatient department patient. We’re in the middle of redefining our workforce to better support our patients. Traditionally, roles are specialized: You’re a scheduler, a financial counselor, a coder or a biller. We’re going to look beyond the historical way of doing things and build new roles; one example is to train one person to act as a navigator for the higher-acuity patient throughout the financial experience, from pre-service to post-service. They face a lot of costs over several months, and we want to help them through that in a coordinated way, not piecemeal.

Kristen Polzin: If I could redesign the patient financial experience, I would move as much as possible to the pre-service stage. Patients should understand their coverage, expected costs, payment options and available financial assistance before receiving care — not after the bills arrive.

Today, our patient access team can identify out-of-network coverage and explain what it means for the patient. However, we have not historically placed a strong focus on collecting at the point of service. We are now developing a process for self-pay patients that allows us to have an upfront, respectful conversation about financial expectations while also connecting patients with financial assistance, especially as upcoming Medicaid changes may affect their coverage.

We also worked with Epic to make our prompt-pay discount more visible in MyChart, even before the service occurs. When we consider the cost of collecting balances later, the discount makes financial sense and gives patients a simpler, more transparent experience.

Jose Celio: We put a lot of work into our self-pay and out-of-network populations. We are trying to figure out an approach to high-deductible in-network families. Many organizations focus financial counseling efforts on out-of-network and self-pay families to determine eligibility for Medicaid or financial assistance. The high-deductible in-network families are often still getting big bills after the fact. We want to engage those families earlier, so they understand both their financial responsibility and the options available to them before care, which likely means engaging patients earlier in the scheduling process. What we don’t want to do is keep waiting until check-in, because then it’s too late, especially as a children’s hospital. Families have taken time off to bring their kids in. They’ll just accept the estimate at check-in and hope to figure it out later. We encourage payment upfront when appropriate, but many balances still require follow-up after the visit.

In a few words, what’s top of mind for you about patient payments?

Bilas: Making cost estimates more accurate and actionable across the provider and payer ecosystem.

Harper: Affordability.

Ryan Klein: Pre-service collections.

Polzin: Culturally, asking for payment at point of service.

Celio: Preparing an accurate estimate for patients with two coverages.

What is your current approach to pre-service financial?

Klein: Our focus is on transparency and expectation setting. We try to help patients understand their out-of-pocket liability prior to services being rendered while also setting the expectation that payment in full is expected. We do offer payment plans, but only after requesting the full balance. When patients complete MyChart pre-registration or e-check-in, their estimated balance is front and center. They can’t get through registration without seeing the payment prompt.

We want to provide an estimate that is as accurate as possible. You need strong inputs and a solid process to achieve this, and that’s something a lot of health systems and offices don’t fully understand. We leverage our EHR [electronic health record] to look at historical charges for the primary CPT code planned and develop an estimated out of pocket balance from there. It’s not perfect, but it does provide us with strong results. We expect to send out approximately 1.4 million estimates in CY 2026 and should have about an 85% accuracy rate [within $50]. I would like our rate to be higher; however, you don’t always know what services are going to be provided, and you have to make assumptions on the information you have.

We now have access to more data than ever. This helps us estimate what a patient’s out-of-pocket liability is going to be, but it is far from perfect. For example, when seeing patients who are out-of-network, we’re going to be honest about what their out-of-pocket costs will be, which are often higher if not seeing a provider in their network. We’re also flagging plans that have limited benefits. If you’re not covered for radiology at a hospital location, we redirect you to a clinic. We don’t want patients to have huge out-of-pocket costs because they don’t understand their benefits.

Taylor Gwinn: We’re located in West Virginia and have a very underserved population, so we are behind on AI and technology. We’ve implemented a patient portal with push notifications to make patients aware of their out-of-pocket costs and the option to pay online or at check-in. There are people who would pay upfront, but they still use checks or cash and didn’t bring a form of payment with them. We are also investing in staff education to help our team understand the whole insurance process — deductibles, copays, coinsurance — so they can have these conversations with patients. We provide good-faith estimates for pure self-pay and insured patients because our insured patients also need to understand their out-of-pocket costs.

At the time of pre-service, we make sure to cover all the core revenue cycle principles: We check for a valid order, run medical necessity, check eligibility to ensure it is accurate, coordination of benefits is updated, a good-faith estimate has been provided and prior authorization has been secured. When the patient presents, we have everything prepared to prevent technical denials and get paid on the back end.

Jacqueline Lilly: If financial conversations occur before the day of service, patients are better prepared to make informed financial decisions. For example, explaining that a prompt-pay discount is available or that payment in full is expected unless alternative arrangements are made, and then offering a payment plan when appropriate, helps set clear expectations. This proactive approach enhances the patient financial experience while also protecting the organization’s financial performance.

What would a dream patient financial experience look like pre-service?

Hodapp: Think about the dentist’s office. If the provider recommends a service, before you leave, the office tells you what it will cost with your current insurance. That’s the dream: The provider orders a CT or an MRI, and while you’re still there, someone says, ‘Here’s the out-of-pocket and upfront payment. If you want to proceed, someone will call you to schedule.’ Quick and easy, so the patient can make their decision without delay.

Gwinn: That’s a very good spin. We can encounter difficulties when a patient shows up for a service and we run the medical necessity check and it fails for their insurer. We might not have the clinical expertise to explain why they need the service. Ideally, while they are still in the ordering physician’s office, we could explain, ‘This is the cost, this is why you really need this care, and this is how we can help you afford it.’

Harper: It would be a dream to have the clinical and non-clinical aspects of billing fully aligned pre-service. Patients need the best outcome for their health, but they also need to be informed about their financial health.

Celio: To help reduce avoidable write-offs, we created a cross-functional committee, bringing together patient access, case management, financial services and other key operational teams. The goal is to ensure key financial and clinical requirements are addressed before care whenever possible: in other words, medical necessity, waivers, prior authorization. It doesn’t mean we say no to out-of-network patients. It means we can have an informed conversation about the patient’s financial options before care.

What does an effective financial clearance strategy look like? Are you using AI or other technology?

Klein: We have a direct real-time connection to our payers, and we financially clear higher-dollar services every time a patient walks in for care or service. Our strategy is about reducing financial risk to both the patient and the health system while setting payment expectations for patients and letting them know all the financial options that exist after the financial clearance is complete. In one letter, we provide our estimate, our expectation for payment in full and information on financial assistance.

Polzin: We use scoring to drive patient conversations. If the score looks like the patient will qualify for Medicaid or need a financial arrangement, that gets funneled to financial counselors. We will be more stringent on the need to pay in full prior to service if they have credit availability. At an organization I was at previously, we had a point system for propensity to pay. If it was a scheduled service, a high-deductible plan and a patient with bad debt, we would reschedule them until the patient’s financing was lined up. We don’t do that here, but I’d like to get to that point to a degree.

We use coverage discovery, and we do find supplemental policies. Maybe patients didn’t realize they had them or didn’t present them. Maybe registration staff didn’t read the full eligibility response or weren’t trained to ask additional questions. It gets back to education of front-end staff.

Hodapp: Patient access really is a primary financial control point. It is not an entry-level position like it was five or 10 years ago. While we try to call patients pre-service, patient access is the only time you’re guaranteed to get hold of a patient before they show up. That means it’s really important to cross-train registration staff to have those conversations with patients.

How do you evaluate new technology solutions?

Harper: Our mantra is to build internally before partnering as long as we can do it right. Otherwise, we want to partner on a co-created solution. Buying off-the-shelf may feel easy, but how often is it really what you need? The reality is we’re all different: rural population versus metro, service scope and so on. I look for partners that can customize, that fit our mission, that are patient first.

Klein: I am put off if a vendor or partner says, ‘This is the opportunity for savings based on the publicly available data.’ They are assuming that our product and practices are standard or average, but there are so many specific things happening in each of our health systems. If there were really a $40 million opportunity, we would have addressed that already. I’m looking for a partner that will dig in to understand what we are doing and customize a solution to our needs.

Conclusion

Roundtable participants agreed that an effective patient payment strategy begins before care, but such a strategy does not simply involve asking patients to pay sooner. It requires accurate estimates, clear explanations of benefits and financial expectations, early screening for Medicaid and financial assistance and payment options that reflect what patients can realistically afford.

Health systems are also broadening how they identify patients who may need support. Financial outreach has traditionally focused on self-pay and out-of-network populations, but affordability challenges increasingly extend to insured patients, particularly high-deductible in-network families who may not be identified until after care. Reaching these patients earlier requires a more thoughtful approach to segmentation based on coverage, financial circumstances, service type and the complexity of the care journey.

This shift is expanding the role of patient access from registration and collections to financial navigation. Success depends on skilled teams, coordination across clinical and revenue cycle functions, and technology that brings estimates, eligibility information and payment pathways into a more connected experience. Patient portals and other digital tools can make support easier to access, while human guidance remains essential for complex or high-acuity cases.

For health systems, the strategic opportunity is to align affordability with financial performance. By identifying the right patients earlier and connecting them with a realistic path forward, organizations can strengthen engagement and collections, reduce downstream work and help prevent cost from becoming a barrier to care.

PANELISTS

NICHOLAS BILAS,
MBA, is associate vice president, patient financial experience at the Hospital for Special Surgery in New York.

JOSE CELIO,
MBA, is patient access financial services director, revenue cycle, for Ann and Robert H. Lurie Children’s Hospital in Chicago.

TAYLOR GWINN,
MHA, is director, patient accounts for Marshall Health Network in Huntington, W.V.

NIKKI HARPER
is chair, revenue cycle analytics, automation and diversified revenue for Mayo Clinic in Rochester, Minn.

PRESTON HODAPP,
BS, CHAM, is director of patient access for Phelps Health in Rolla, Mo.

RYAN KLEIN
is senior director, patient access and financial experience for UW Health in Milwaukee.

JACQUELINE LILLY
is senior director of healthcare access for Cooper University Health Care in Camden, New Jersey.

TOBIAS MEZGER
is cofounder and chief revenue officer for PayZen in San Francisco.

KRISTEN POLZIN
EHCR, CRCR, MSA, is associate vice president, patient financial services for WVU Medicine in Morgantown, West Virginia.

About PayZen

PayZen is the AI healthcare affordability platform making care accessible for patients and sustainable for health systems. With the most comprehensive AI data platform and a patient-first mindset, PayZen delivers custom payment options tailored to the individual, helping patients afford the care they need while improving financial outcomes for providers. Recognized by KLAS Research as the top vendor in the space, PayZen is backed by leading investors and led by experienced technology leaders with a proven track record of helping millions of Americans overcome financial challenges. Learn more at payzen.com.

_{This published piece is provided solely for informational purposes. HFMA does not endorse the published material or warrant or guarantee its accuracy. The statements and opinions by participants are those of the participants and not those of HFMA. References to commercial manufacturers, vendors, products, or services that may appear do not constitute endorsements by HFMA.}