In the first quarter, a large share of what a practice earns is owed by patients rather than payers. Deductibles reset on January 1, and until each patient meets theirs, the payer's remit says allowed $142.60, paid $0.00, patient responsibility $142.60. The practice did the work, the payer agreed on the price, and the money is now a collections problem.
This year the numbers are bigger. The Medicare Part B deductible rose to $283 (from $257 in 2025). On the marketplace side, the enhanced premium tax credits ended on December 31, 2025, and the early reports on open enrollment show many enrollees choosing bronze plans with lower premiums and much higher deductibles, or dropping coverage entirely. Employer plans with deductibles above $3,000 are ordinary. A practice that waits for statements to do the collecting will spend the spring chasing balances it could have collected in the lobby.
Key takeaways
- Time-of-service collection depends on knowing the number before check-in: deductible remaining from the 271 response plus the contracted allowed amount for the scheduled visit type.
- The script that collects assumes payment and offers a choice between card and payment plan; the script that asks "would you like to pay anything today" collects nothing.
- A payment plan is a card on file with an automatic monthly charge; anything else is a promise.
- Read secondary coverage before quoting a Medicare patient anything. The $283 Part B deductible is the patient's only if no supplement covers it.
- Track the time-of-service rate, patient AR over 60 days and refunds every week in the first quarter; the refund count tells you whether estimates are calibrated.
Know the number before the patient arrives
Time-of-service collection depends on one thing: knowing what the patient owes before they check in. That means an eligibility response that includes deductible remaining and copay, read the day before the visit, and an estimate built from your contracted allowed amount for the expected service. The 271 response from most payers now returns deductible remaining for the plan year; in the first week of January it will read as the full deductible for almost everyone.
Build the estimate from the visit type on the schedule. A 99214 with a contracted allowed amount of $135 for a patient with $2,800 of deductible remaining is a $135 estimate. A patient with a $30 copay and a met deductible is a $30 estimate. The front desk does not need to understand the fee schedule; they need the number on the screen and a script.
The script that works
We have listened to a lot of check-in conversations. The ones that collect are direct and assume payment. "Your insurance shows your deductible hasn't been met yet this year, so today's visit is estimated at $135. Would you like to pay by card or would a payment plan help?" The ones that don't collect ask whether the patient would like to pay anything today. Nobody wants to pay anything today.
Two rules for the staff. First, the estimate is an estimate, and they say so: the final amount depends on what the doctor does and how the insurer processes it, and any difference is refunded or billed. Second, the patient who cannot pay is offered a plan, not a lecture. The goal is a commitment, not an argument.
Payment plans that actually get paid
A payment plan is a card on file with an automatic monthly charge. A payment plan that depends on the patient mailing a check is a promise. For balances under $500 we suggest a maximum of three months; for larger balances, six, with a minimum monthly amount the practice sets. Get written consent for the card on file, store it in the payment processor rather than in the practice management system, and send a receipt for every charge. Practices that put these rules in writing collect a much higher share of patient responsibility than practices that improvise at the counter.
Medicare patients without a supplement
A meaningful share of traditional Medicare patients have no supplemental coverage. For those patients the first $283 of allowed charges in 2026 is fully their responsibility, and after that they owe 20 percent. The eligibility response shows whether the Part B deductible has been met. A patient with a Medigap plan will have the deductible paid by the supplement, or on Plan G will owe only the Part B deductible itself. Train the front desk to read the secondary coverage before quoting a Medicare patient anything; quoting $283 to a patient whose supplement covers it creates a refund and a complaint.
The arithmetic for a patient with no supplement is worth writing on a card. A 99214 with a Medicare allowed amount of $130 on January 8, deductible unmet: the patient owes $130, all of it deductible. The same patient returns January 29 for a 99213 allowed at $92: the remaining deductible is $153, so the full $92 is again deductible. A third visit in February for a 99214 at $130: $61 finishes the deductible and 20 percent of the remaining $69, which is $13.80, is coinsurance, so the estimate is $74.80. After that the patient owes 20 percent of the allowed on every visit for the rest of the year. Medicare's eligibility response returns the deductible remaining, so the front desk does not have to do this by hand, but the staff should understand why the first three estimates of the year are so different from each other.
Marketplace patients: verify, then estimate
Patients who had a subsidized silver plan in 2025 may have a different plan, a different network or no coverage in January. Run eligibility for every marketplace patient before the visit and confirm the practice is in network for the new plan. If the response shows terminated, call the patient before the appointment rather than discovering it at check-in. A bronze plan with a $7,000 deductible is coverage, but for most office visits it functions as self-pay, and the patient should hear the estimate before they arrive.
The reports to watch
| Measure | How to calculate | What we look for in Q1 |
|---|---|---|
| Time-of-service collection rate | Patient payments at visit divided by estimated patient responsibility at visit | Rising week over week; a practice new to estimates often starts below half |
| Patient AR over 60 days | Patient balances aged more than 60 days from statement date | Should not grow faster than patient charges |
| Statement to payment lag | Days from first statement to payment | Shorter when a text or email statement precedes the paper one |
| Cards on file | Share of active patients with a stored payment method | Growing every month |
| Refunds issued | Count and dollars of patient refunds | Some refunds mean estimates are working; many mean they are too high |
Where practices go wrong
The first mistake is skipping estimates for established patients on the theory that they know the drill. In January nobody knows the drill; their deductible reset. The second is letting the physician decide who gets asked to pay. Collections policy belongs to the practice, applied to everyone, with a documented hardship process for exceptions. The third is sending the first statement 30 days after the remit. Send it within a week, and send an electronic version first. The fourth is treating the No Surprises Act good faith estimate for self-pay patients as a nuisance; it is a collections tool, because a patient who received a written estimate pays more often than one who didn't.
Our medical billing team builds the estimate workflow with the front desk in the first month of an engagement, and the monthly report includes the time-of-service rate so the practice can see it move. Practices that want to compare their numbers against what we see can book a call.
Questions we hear
Can we collect the deductible before the insurer processes the claim?
For most commercial plans and Medicare, yes, as an estimate, with the understanding that you reconcile to the remit. Check your contracts; a few payers restrict collecting more than the copay at the time of service. Medicaid patients generally cannot be charged beyond nominal copays, so exclude them from the estimate workflow.
Our patients complain about being asked to pay at check-in. Should we stop?
In our experience the complaints fall off after a few weeks once patients know the policy, and they fall off faster when the estimate is communicated before the visit by text or in the reminder call. What does not fall off is the balance you never collected.
Do we need a written financial policy for this, or is the script enough?
Write it down. A one-page financial policy that says estimates are collected at the time of service, describes the payment plan terms, and describes how a patient can request a hardship arrangement protects the practice in two ways: staff apply it the same way to every patient, and a patient who complains can be shown the policy they signed at registration. It also keeps the physician out of the decision about who pays, which is where most inconsistent collections start.
What to do this month
- Confirm the eligibility response for every scheduled patient includes deductible remaining and copay, and that it runs the day before the visit.
- Build estimates from visit type and contracted allowed amounts for your top five payers, and put the number on the check-in screen.
- Train the front desk on the two scripts, the estimate disclaimer and the payment plan offer.
- Set up card-on-file payment plans in the payment processor with written consent and automatic receipts.
- Update the Medicare estimate logic for the $283 deductible and add a secondary coverage check before any Medicare quote.
- Start the weekly report: time-of-service rate, patient AR over 60 days, cards on file and refunds.
