By Emmanuel Bobby
For years, patients generally expected to receive a medical bill after an appointment, procedure or hospital stay. But that practice is changing as hospitals and other medical providers increasingly ask patients to make substantial payments before receiving care.
For Thomas Zordani, the issue became personal when he traveled from his home in Denver to Phoenix for an appointment with a neurosurgeon at Mayo Clinic. Zordani was seeking answers about debilitating headaches after concerning findings on brain scans, and he believed the appointment was an important step toward determining what treatment might be available.
When he scheduled the consultation, Zordani said he was told the clinic was within his health insurance network. But when he arrived for the appointment in April 2024, he said he was directed to a financial office and told he would have to provide a $5,000 preservice deposit.
Mayo had determined that it did not accept his insurance, according to Zordani, and he was automatically classified as a self-pay patient despite having insurance coverage that included out-of-network benefits.
Zordani did not have $5,000 available to hand over and objected to being required to pay before seeing the doctor. He ultimately refused the deposit, and his appointment was canceled.
“I was so livid,” Zordani said.
The situation became even more frustrating when Zordani later discovered that Mayo had sent a message through his insurance company’s patient portal shortly before the appointment estimating his cost at $565 — substantially less than the $5,000 deposit he was asked to provide when he arrived.
Mayo later acknowledged that the experience did not meet its standards for communicating with prospective patients about insurance coverage and financial obligations.
“We regret that this individual’s experience did not meet the high standard of communication we strive to provide when helping our patients understand their insurance coverage and financial responsibility,” Andrea Kalmanovitz, Mayo’s communications director, said in a statement.
The situation highlights a growing issue in American health care: patients are increasingly being asked to pay some or all of their expected financial responsibility before receiving nonemergency treatment.
Hospitals Are Collecting More Before Treatment
The increase in upfront medical payments is occurring as patients are already responsible for a larger share of their health care costs.
Deductibles, coinsurance and other forms of cost-sharing have become a major component of many insurance plans. As medical costs continue to rise, insurers have increasingly shifted some expenses to consumers as a way of limiting premium increases.
That means patients can face thousands of dollars in expenses before their insurance begins paying a larger portion of their medical bills.
Richard Gundling, a senior vice president at the Healthcare Financial Management Association, said the trend effectively means some patients are being asked to take on more of the financial risk themselves.
People are “basically being asked to self-insure,” Gundling said.
Hospitals, meanwhile, are also concerned about whether patients will ultimately be able to pay what they owe.
As more patients have high deductibles and substantial out-of-pocket obligations, providers are attempting to collect money earlier in the process rather than waiting until after care has been delivered and bills have been processed.
Chip Kahn, a visiting senior fellow at KFF and the American Enterprise Institute and former president and CEO of the Federation of American Hospitals, said preservice deposits are likely to become increasingly common.
“Things like preservice deposits and those kinds of moves are probably going to become more and more likely,” Kahn said.
The practice creates difficulties for both patients and providers, he said, because patients may not have the money available while hospitals are trying to protect themselves against unpaid bills.
The larger question, Gundling said, is how the health care system can maintain access to treatment when more patients cannot afford their required share of medical expenses.
Deductibles Continue to Put Pressure on Consumers
Health care costs have become a major concern for Americans with insurance.
A recent KFF health tracking poll found that reducing out-of-pocket costs was the top change insured adults wanted from their health coverage.
The financial burden can be especially significant for families with high-deductible insurance plans.
According to KFF, the average deductible for family coverage offered through employers was $3,762 per person in 2025. Average deductibles for Affordable Care Act marketplace plans also increased substantially, reaching approximately $3,786 in 2026.
For a patient already facing several thousand dollars in deductible expenses, being asked to provide a large payment before treatment can create an additional barrier to care.
Patients may have to delay appointments, borrow money, use credit cards or tap into savings to cover the requested payment.
For people seeking treatment for serious or complex medical conditions, delaying care may also create additional health concerns.
Consumers Are Raising Questions About Upfront Charges
Consumer advocates say they are increasingly hearing from patients who are confused or concerned about preservice payments.
Diane Spicer, a supervising attorney with Community Health Advocates, a New York-based health insurance consumer assistance organization, said the issue often affects people seeking out-of-network treatment despite having insurance that includes some out-of-network benefits.
“We see this mostly with insured folks who are seeking out-of-network care but who have out-of-network coverage,” Spicer said.
Patients may assume that because their insurance provides out-of-network benefits, the provider will simply bill the insurer and then send the patient a bill for whatever portion remains.
Instead, some providers are asking for substantial payments before the appointment takes place.
The number of hospitals routinely collecting these payments is difficult to determine.
Matt Szaflarski, a vice president at Kodiak Solutions who leads the company’s revenue cycle intelligence team, said upfront collections are becoming a more common subject in conversations with health systems.
Kodiak analyzed information from more than 2,300 hospitals and found that providers are collecting a larger portion of estimated patient responsibility before treatment.
Szaflarski said hospitals collect roughly one-quarter of what they expect patients will owe on average, based on their estimates of what insurers will pay.
That percentage has increased in recent years.
For example, if a hospital expects an insurer to reimburse $1,000 for an imaging procedure, the hospital might seek $250 from the patient before the service is performed. Szaflarski said the amount previously would have been closer to $150.
The practice varies from hospital to hospital and from state to state.
Providers Are Also Struggling With Unpaid Bills
The increase in upfront collections does not mean hospitals have eliminated their financial problems.
Kodiak’s data shows that uncollected patient debt has also been increasing.
The company attributed the trend to changes in insurance coverage, including higher deductibles, greater coinsurance requirements and increasingly complicated cost-sharing arrangements.
Those changes can increase the amount patients technically owe while simultaneously making it more difficult for hospitals to collect the money.
Hospitals can estimate what a patient will owe based on the information available at the time, but the final amount can change after the insurance company processes the claim.
That creates another problem for patients who have already paid a deposit.
The eventual insurance payment may be different from what the hospital originally anticipated. Other providers involved in the same procedure, such as surgeons or anesthesiologists, may also submit claims that affect how much of a patient’s deductible remains.
The result can be an overpayment.
When Can Hospitals Require Payment?
There are important differences between emergency and nonemergency care.
Federal law generally prevents hospitals participating in Medicare from demanding payment before stabilizing a patient who arrives at an emergency department with an emergency medical condition.
Outside emergency situations, however, the rules surrounding preservice deposits are less straightforward.
Patients receiving in-network care may have protections contained in their insurance contracts, according to health policy experts. Those protections can vary depending on the insurance plan and circumstances.
Out-of-network care can be more complicated.
Matthew Fiedler, a senior fellow and health policy researcher at the Brookings Institution, said he is not aware of broad restrictions preventing an out-of-network provider from requiring a preservice deposit.
That leaves consumers with an important responsibility: understanding both their insurance policy and the provider’s payment requirements before traveling for care.
Patients May Not Know How Deposits Are Calculated
Another concern is the lack of transparency surrounding the amount providers request.
Patricia Kelmar, senior director of health care campaigns at PIRG, said patients may have difficulty determining whether a requested deposit represents their remaining deductible, a percentage of the expected bill or another calculation.
“They could just say $1,500 and you’d be like, ‘Oh, is that 10%, or is that how much is left on my deductible?’” Kelmar said.
The problem is particularly complicated when an appointment is scheduled months in advance.
A provider may not know exactly how much of a patient’s deductible will remain by the time treatment occurs.
Consumer advocates recommend that patients ask providers for an itemized explanation of the requested payment and contact their insurance company directly.
Patients should ask the insurer how much of their deductible has already been met and whether the proposed payment is consistent with the terms of their plan.
They should also ask what happens if the provider’s estimate turns out to be higher than the final amount owed.
What Happens When Patients Overpay?
Refunds are another potential source of frustration.
Patients can overpay when a procedure costs less than initially estimated or when an insurer ultimately covers more of the bill than expected.
For example, a hospital might calculate a preservice payment based on a patient’s remaining deductible. But if another medical provider submits a claim first and the insurance company applies that expense toward the deductible, the hospital’s original estimate may no longer be accurate.
In those situations, the patient may have paid too much.
How quickly the money is returned can vary depending on the provider and state law.
Some states have enacted specific requirements governing refunds. Florida, for example, now requires medical providers to issue refunds within 30 days after determining that a patient has overpaid.
Other states have adopted restrictions on certain forms of prepayment, particularly when the payments could interfere with access to financial assistance.
The issue has also attracted attention from state attorneys general.
Zordani Eventually Found Another Specialist
After his Mayo appointment was canceled, Zordani returned to Denver and began searching for another specialist.
He eventually received treatment in June 2024 at a Denver-area hospital unaffiliated with Mayo.
Doctors diagnosed and treated him for a spinal fluid leak.
The dispute with Mayo did not end there.
Zordani later filed a complaint in Arizona civil court. In September 2025, an arbitrator awarded him $47,500 in economic damages and attorney fees after determining that Mayo had violated an Arizona consumer fraud law.
The arbitrator found that Mayo had failed to properly notify Zordani that his insurance plan was not considered in-network before he traveled to Phoenix.
Zordani said that if he had received timely notification, he would not have made the trip.
“Had they notified me in timely fashion as required, I would not have flown there,” he said.
He also continues to question how Mayo calculated the $5,000 preservice deposit and why the clinic designated his care as self-pay rather than allowing him to use the out-of-network benefits available through his insurance plan.
What Patients Can Do Before Paying Upfront
Health care experts say patients who are asked for a large payment before treatment should take several steps before handing over the money.
First, patients should contact their insurance company directly rather than relying solely on information provided by a medical provider. They should confirm whether the doctor, hospital or facility is in-network and determine what out-of-network benefits are available.
Patients should also ask for a written explanation of the requested payment and find out how the amount was calculated.
If the provider is estimating the patient’s deductible responsibility, consumers should ask whether the estimate can change after the insurer processes the claim.
Patients should also ask about the provider’s refund policy if the final bill is lower than the amount paid upfront.
For expensive or specialized treatment, consumers may want to compare the provider’s estimate with the insurer’s own estimate of the patient’s responsibility.
Patients should also be cautious about assuming that a provider’s statement about insurance coverage is the same as a formal determination by the insurance company.
A Growing Challenge for the Health Care System
The rise of preservice payments reflects a much larger problem in the American health care system.
Hospitals are dealing with rising labor, drug and operating costs while insurers and employers are attempting to control premiums. One consequence has been the growth of insurance plans that require consumers to pay more before their coverage becomes substantial.
At the same time, hospitals are becoming more aggressive about collecting those payments.
For providers, collecting money upfront can reduce the risk of unpaid bills. For patients, however, the practice can turn an insured medical appointment into a significant financial hurdle before treatment even begins.
The situation can be particularly difficult for patients who travel long distances to receive specialized care. A patient may make airline reservations, arrange transportation and take time away from work or family responsibilities based on the assumption that the appointment is covered by insurance.
If the provider later determines that the insurance is not accepted and demands thousands of dollars before the appointment, the patient may have few practical options.
Zordani’s experience demonstrates how quickly an insurance misunderstanding can become a barrier to medical care.
As more hospitals seek payment before providing nonemergency services, consumer advocates say patients will need to become increasingly proactive about understanding their coverage, confirming provider participation and questioning unexpected financial demands.
For hospitals and insurers, meanwhile, the challenge will be finding ways to collect appropriate payments without making necessary medical care inaccessible to people who cannot afford large upfront bills.
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