Ensuring practices, ASCs, and hospitals get paid is a complex process involving multiple players. The road to account resolution begins with the provider, continues through insurance claims processing, and often involves revenue cycle management companies addressing claim denials and other sources of revenue loss.
And yet, practices still experience multiple revenue cycle leaks along the way. A 2026 Medical Group Management Association (MGMA) survey of medical group leaders revealed that their biggest revenue leaks included 48% from insurance denials and appeals, 23% from front-end issues, and 14% from billing and/or collections.1
A coordinated process that resolves balances after insurance while addressing the billing cycle end-to-end can help make billing processes easier and smoother. Unfortunately, key players are fragmented with roles and responsibilities that intersect on paper far more than in practice, resulting in multiple bills and statements that can confuse patients and compromise patient billing satisfaction.
The Roles of Insurance Companies and RCMs in Patient Pay
Insurance companies process claims and explain benefits, entering the picture after procedures are delivered. For patients, that means identifying what plans have paid and what they may owe through a standard Explanation of Benefits (EOB). EOBs aren’t bills or proof of payment; they explain how a claim was processed and what portion of the cost may become the patient’s responsibility.2 The responsibility of patient pay falls squarely on the provider.
The bills that follow from healthcare providers can be just as confusing as EOBs. Bills include different amounts, including total charges, how much insurance was paid along with what was already paid and what’s still owed.3 Healthcare providers are also limited in their ability to collect on patient AR; they can’t pursue collections for cases that qualify for financial assistance, and may be subject to state laws that limit monthly payment amounts and/or interest.4
By contrast, revenue cycle management (RCM) is how healthcare systems track revenue from patients, including every step that leads to payment for services rendered, from patient registration to verification of benefits to care delivery.5
Best practices for revenue cycle management include pre-service financial communications, and that account resolution companies or business affiliates be under contract with the provider.6 Healthcare providers may partner with standalone RCM companies to help collect on patient AR efforts. However, while RCMs may touch on collections, they don’t necessarily provide end-to-end resolution support. In some cases, the burden of unresolved balances may shift to debt collection firms when patient AR resolution exceeds their capabilities.
Solving the Patient Pay Challenge with Proactive, Patient-Centric Solutions
A patient AR optimization and resolution partner can help ensure that healthcare providers can collect patient AR early on in the process, ensuring pre-service financial communications take place before patient balances become more difficult to resolve.
PatientFocus closes the gap between insurance and RCMs, acting as an extension of the revenue cycle for practices. End-to-end patient balance resolution, combining smart outreach with real patient support, helps ensure that EOBs and ensuing bills are easy to understand and act on. A bilingual call center and convenient digital tools make account reconciliation more efficient. Advanced analytics further help predict and tailor engagement strategies, delivering better patient financial and payment outcomes.
PatientFocus’ proactive approach and easy payment options put providers on a glidepath to successful account resolution, delivering a 20%-40% lift in collections that’s 63% faster than the industry average.7
Moving Patient AR Forward
While the patient pay landscape remains complex, PatientFocus helps simplify the process for providers and patients alike. We go beyond basic billing follow-up, with an AR optimization platform that resolves balances after insurance and helps patients early on so that bills make sense and payment is simple.
By adopting a proactive approach to patient pay, practices can reduce revenue cycle leaks while improving the patient financial experience. PatientFocus patient pay solutions put patients first with tailored solutions that meet them where they are while demystifying the billing process.
Let’s connect to see how we can help your organization strengthen patient financial engagement with a more connected approach to the patient pay journey.
Sources
- MGMA. “Detecting and fixing leaks across the revenue cycle. MGMA Stat, January 7, 2026. https://www.mgma.com/mgma-stat/detecting-and-fixing-leaks-across-the-revenue-cycle
- Centers for Medicare & Medicaid Services. “How to read an explanation of benefits.” https://www.cms.gov/medical-bill-rights/help/guides/explanation-of-benefits
- Centers for Medicare & Medicaid Services. “How to read your medical bill.” https://www.cms.gov/medical-bill-rights/help/guides/how-to-read-bill
- The Commonwealth Fund. “State Protections Against Medical Debt: A Look at Policies Across the U.S.” July 2025. https://www.commonwealthfund.org/publications/fund-reports/2025/jul/state-protections-against-medical-debt-look-policies-across-us
- Healthcare Financial Management Association. “Healthcare Revenue Cycle Management (RCM)—What It Is & How It Works.” https://www.hfma.org/reference/revenue-cycle-management
- Healthcare Financial Management Association. “Best Practices for Resolution of Meidcal Accounts Executive Summary.” https://www.hfma.org/guidance/healthcare-dollars-and-sense/best-practices-resolution-medical-accounts-executive-summary
- Internal data on file: PatientFocus