Health system revenue heads increasingly turning their attention to patients' share of the bill

Patient collections are playing a bigger and bigger role in health systems’ total revenues, bringing a new focus on the difficulties organizations face in securing timely, or any, payments for their services, a new survey report warns. 

The poll of 205 healthcare revenue heads, conducted by healthcare fintech vendor PayZen and the Healthcare Financial Management Association, found that 22% of respondents named patient balances as their top priority, roughly double the 11% rate reported a year prior. Patient balances were a “nearly universal” presence among the respondents’ concerns, also up from the 73% rate of a year prior. 

Commercial revenue remained the respondents’ overall top priority, though the portion who indicated so dipped from last year’s 75% to 62%. Government program revenue also inched upward from 13% to 16%, naming it their top revenue concern. 

Still, PayZen said the shift reflects “a new financial reality” in which increased premiums, high-deductible plans and stricter Medicaid eligibility are placing patients on the hook for a larger portion of the bill. According to the responses, patient billings accounted for 12% of health systems’ total net patient revenue despite only 31% of total patient billings being collected on average. 

“When patients were secondary payers, the financial conversation could wait until after care was delivered,” Itzik Cohen, CEO of PayZen—which sells patient financing and engagement tools to providers—wrote in a foreword to the report. “That era is over. … Patients are now increasingly the payer. And health systems across the country are designing a new blueprint for this reality.” 

PayZen noted in its report that the 2026 survey had greater representation among larger systems with $200 million or more annual revenue, meaning that its year-over-year comparisons shouldn’t be viewed as absolute differences so much as “directional markers of where the market is headed.”

When asked about top priorities specifically within the realm of patient balances in the latest survey, just under half of the respondents said they are focused on increasing new collections, 41% on improving the patient financial experience, 41% on reducing bad debt, and 36% on reducing days in accounts receivable. 

Here, the report noted some differences in reported revenue priorities based on the size of respondents’ organizations. Larger health systems ($5 billion-plus revenue) more often named “reducing bad debt” and “improving patient financial experience” as top priorities than smaller organizations (less than $1 billion revenue), though the reverse was true for “reducing days in [accounts receivable].” 

The report also outlined gaps in systems’ financing offerings and awareness of how often patients are defaulting on system-run payment plans. 

For the former, 8% said they didn’t offer any in-house payment plans to patients, which increased to more than 16% among the systems with less than a billion in revenue. Nearly three in five said their in-house payment plans are capped at 24 months, which PayZen said “virtually guarantees higher default rates,” considering patients’ limited ability to allocate monthly funds toward healthcare. 

Meanwhile, 72% of the polled revenue leaders said their organization does not have a handle on their average default rates for in-house payment plans. Those that did described an average default rate of just over 13%—a rate PayZen said is substantially lower than the 20% it found in its own separate evaluations and “suggests that organizations may be underestimating their internal risk by more than 50%.” 

About 44% of respondents said they use third-party patient financing, up from the prior survey’s 38%, with adopters most often (36%) citing cash acceleration as their top priority when doing so. 

Pre-service payment policies also appear to be increasing in adoption, rising from 81% in 2025 to 92% in 2026 and more often embraced by larger systems—though average pre-service collection rates grew more slowly, from 16% to 21%. 

New technology is also playing a role in the process, with 37% of respondents saying their system is already using generative AI in their revenue cycle and 85% of the remainder saying they are interested in doing so. Adoption was more common among the survey’s larger systems, with denials management and appeals leading deployments (45%). 

PayZen’s topline findings around increasing patient burden echoes predictions given by health system executives to analysts as well as other reports. Kodiak Solutions, whose platform has insight into thousands of hospitals and physicians’ revenue cycle data, said last month that insured patients in 2025 were responsible for 7.3% of their bills, up from 2024’s 6.8%. They also paid less of what they owed, Kodiak said, with insured patient yield dropping from 45.1% in 2024 to 42.4% in 2025.