Amid growing patient pay options, complexity surges

Hospitals are offering patients more payment options than ever. But fragmentation and manual workarounds are proliferating, according to a recent survey.

Sixty-eight percent of 150 respondents, most of whom were hospital finance officials, said they support nearly all of the digital payment options their patients would like to use, according to a survey by Elavon, a subsidiary of U.S. Bank, and Healthcare Dive.

However, 46% cited continued friction enrolling patients in payment plans and 44% reported gaps between EHR, billing and payment system integrations.

“The biggest surprise was how much modernization has happened while some of the underlying friction remains to be solved,” Wally Mlynarski, CEO of Elavon, said in email comments regarding the survey. “Technology is largely there, yet only 15% of respondents rated their end-to-end revenue cycle performance as excellent.”

That disconnect requires organizations to focus on tying together those systems and processes, he said.

Disconnect challenges also included 76% saying up to 20% of staff time is spent managing exceptions or correcting errors.

That complexity hits revenue, with 44% reporting delays in collections because of gaps or limitations in internal system integrations.

Industry challenge

Challenges in the collection of patient share of charges come as growing commercial out-of-pocket costs are hitting hospital uncompensated care. Bad debt and charity as a percentage of gross operating revenue increased 14% year-to-date 2026 compared with year-to-date 2023, according to the latest Kaufman Hall hospital tracking report.

And commercially insured individuals with average incomes are avoiding care at the highest rates because of cost concerns, a recent survey found.

Preservice collections as a share of self-pay collections have improved from an average of 16% in 2025 to 21% in 2026, which signals that more organizations are capturing revenue successfully before care is delivered, according to a survey earlier this year of healthcare revenue cycle leaders by PayZen and HFMA.

Overall, health systems reported in 2026 that they collected 31% of total patient billings, an improvement from 24% of total patient billings reported in 2025.

Leading barriers

Instead of a lack of payment options, the Elavon survey found the leading barriers to patient payment resolution were continued paper plus digital channel reliance, friction enrolling in payment plans and EHR-billing-payment system gaps. Those highlight that the challenges are occurring in the systems that surround payment options, Mlynarski said.

For example, on EHR-billing-payment gaps, Mlynarski noted that a payment doesn’t end when the transaction goes through. It still must be posted, reconciled and reflected in reporting. Before looking at new technology, hospitals and health systems need to understand how that work happens today, where the process breaks down and where staff are bridging gaps between systems. Only then can they identify the technology and integration gaps that need to be addressed. 

Vendor proliferation

The increased payment options also have come amid vendor proliferation. Most respondents said that working with multiple vendors significantly contributes to operational friction.

But consolidating vendors may just shift complexity from vendor management into another part of the organization, he said.

Instead, healthcare organizations should focus on ensuring that their patient payment systems result in fewer handoffs, less manual work and a more consistent way to operate across your end-to-end revenue cycle.

“It is also best to work on a plan for implementation across vendors to drive the best outcomes and remove unnecessary frictions where you can,” Mlynarski said.

Investment priorities

Hospitals continue to invest in patient payment transformation and revenue cycle, according to Elavon. But the focus on those investments have shifted from broad modernization to those that improve scalability, strengthen operational capacity and support long-term growth.

Specifically, 56% said scalability is a primary factor when evaluating strategic partners.

Meanwhile, the catalysts driving investment decisions include:

• 20% scalability constraints
• 20% security and compliance
• 19% revenue pressures

As nearly all respondents said they are investigating investments in AI-driven options, Mlynarski warned that AI can amplify existing system issues.

“So, you want to apply it to a well-designed workflow rather than use it to work around a fragmented one,” he said. “Then, AI has a much better chance of simplifying the work instead of adding another layer to manage.”