Practice owners keep telling me the same thing, in the same confused tone: patient volume is up, claims volume is up, and collections are somehow getting harder. That’s not a staffing problem and it’s not a patient-mix problem. It’s a quiet structural shift in how some Medicare Advantage plans are handling cost-sharing — and it’s moving financial risk from the payer’s balance sheet to yours, one claim at a time.
Here’s the mechanism, reported this week by Medical Economics, and it’s worth walking through slowly because the sequence is the whole story.
A patient comes in. Front desk checks eligibility, sees the expected copay, collects it at time of service — standard practice, the way it’s worked for years. The claim goes out. Somewhere in adjudication, the plan’s claims logic reclassifies the service, or applies a different benefit category than the one the front desk checked against, or determines the patient’s actual responsibility is different from what was collected. Now the practice is sitting on a mismatch: money it already collected that it may need to refund, or a balance it should have collected but didn’t. Multiply that across a full patient panel and you get exactly what practices are reporting — rising A/R, rising administrative overhead spent chasing reconciliation, and rising bad debt on the balances that never get resolved cleanly.
The reason this is happening now, rather than being a permanent feature of Medicare Advantage, comes down to interpretation. According to the Medical Economics report, a shift that took hold in October 2024 has led some Medicare Advantage plans to require adjudication to run its full course before a patient’s true financial responsibility is considered final — rather than treating the point-of-service estimate as reliable enough to collect against. That’s a small technical change in how a rule is read. It has an outsized effect on cash flow, because it inserts a lag, and often a discrepancy, between the moment a practice would normally collect and the moment the amount owed is actually locked in.
If you run collections at time of service — and collecting at the point of service is one of the most reliable ways to capture patient-owed dollars before the patient walks out the door — you are now structurally exposed to a gap that didn’t exist a few years ago. You collect based on an estimate. The plan finalizes something different later. You either refund or you chase a second collection, and both of those cost more, in staff time and in patient goodwill, than getting it right the first time would have.
What can a practice actually do about this, given that the rule change is coming from the payer side and isn’t something an individual practice can negotiate away?
Start by separating “estimated” from “confirmed” in your own internal language and your own patient communication. If your front-desk collection is explicitly framed to the patient as an estimate pending adjudication — not a final bill — you reduce the friction and the ill will when a refund or a follow-up statement is required. That’s a scripting and documentation fix, and it costs nothing beyond training.
Second, track your Medicare Advantage claims separately in your A/R aging, not blended into your general payer mix. If MA claims are driving a disproportionate share of your aging balances or your refund volume, you need to see that number on its own to know whether the problem is growing and by how much.
Third, revisit how aggressively you’re collecting the full estimated copay versus a conservative partial amount at time of service for MA patients specifically. This is a real trade-off — collect less up front and you protect against refund exposure, but you also slow your point-of-service collection rate, which is one of the best cash-flow levers a practice has. There’s no universally right answer here; it depends on your payer mix and your historical adjudication variance, and it’s worth actually running the numbers on your own claims rather than guessing.
Fourth, if a meaningful share of your adjudication outcomes differ from your point-of-service estimate, that’s worth escalating — through your billing service, your clearinghouse, or directly with the plan — because a pattern of systematic reclassification is a different problem than occasional adjudication noise, and it may be worth challenging at the contract or appeals level rather than absorbing quietly.
The plans didn’t send a memo announcing this shift. It showed up in the aging report instead. That’s usually how it goes.
Source: Glenn N. Pomerance, M.D., “Why Physicians Can’t Collect Medicare Advantage Copays Like They Used To,” Medical Economics, August 11, 2026. The article describes an October 2024 shift and its reported effects on Medicare Advantage practices; it is an industry analysis rather than a CMS policy announcement.
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