With a record number of Americans newly without health insurance, surgery centers face additional financial challenges as they cope with the COVID-19 pandemic. To survive, surgery centers will have to stay flexible and work closely with patients on payment plans.

  • Surgery centers may need to adjust existing policies regarding preservice payments. For example, instead of asking for 50% payment, a center could ask for 25%.
  • Some patients who are making payments for surgeries that were performed already might need a little more time to retire their debt.
  • Educating patients on various payment options, including applying for Medicaid and signing up for insurance through Affordable Care Act exchanges, is crucial to improving collections.

The COVID-19 pandemic led to job losses, which in turn caused 5.4 million laid-off Americans to lose their health insurance between February and May.1

From a surgery center’s perspective, this means some patients on payment plans fell behind in their payments. Other patients who wanted to schedule surgery may have to pay more out of pocket and need flexible repayment terms.

“We need to loosen some of our tight restraints to allow a little more flexibility,” says Jessica Weathers, CPC, revenue cycle manager at Proliance Surgeons, Inc. in Seattle. “It’s all new for all of us, and we’re trying to manage it. Our philosophy now is we’re trying to adapt to this and make surgery feasible for a patient.”

Proliance Surgeons owns 20 surgery centers, which were closed to elective cases from March to May. Since then, the centers have reopened, and employees are working through backlogs, Weathers reports.

The organizations work with a decentralized structure — separate leadership, boards, policies, and procedures. But the offices also collaborate on what is working from the revenue side of the business. “We ask each other, ‘What is working for your office? How are you approaching these scenarios?’” Weathers says.

The surgery centers accept bank checks, debit cards, and credit cards for payment of patients’ out-of-pocket expenses. Staff typically ask patients pay half their estimated out-of-pocket costs, including copays and deductibles, up front. Then, the centers place the remainder on a repayment plan that usually lasts 12 months or less, depending on the amount, Weathers explains.

For instance, if a patient owed $500 after the procedure, they would be put on a plan to repay within four or five months. However, the pandemic has changed practices.

“It’s a different time than it was [in February] when the unemployment rates were very low and the uninsured rates were low,” Weathers says. “Everyone has to change their tone and mindset in how they approach this situation. It will keep evolving, probably get worse before it gets better.”

Weathers offers these techniques for improving collections from patients during the pandemic:

Work with post-surgery patients on their repayments. Revenue cycle staff talk with patients who are behind in their payments to see whether they need some flexibility in their repayment schedule, Weathers says.

“Before COVID, we’d recommend that anyone who owed $500 or less repay it within five months,” she says. “Now, we are extending it to eight months.”

It is important to be creative and allow patients more time to pay off their surgery debt. Centers can extend their monthly payments to make them more affordable, Weathers offers. “We have a lot of folks who don’t work and are trying to juggle what they can pay right now,” she observes. “We find that a lot of us are making concessions, trying to make a more affordable payment plan, where we had an account under 12 months, and now are pushing these out longer, allowing a little leeway.”

Sometimes, centers will allow patients to skip a month. Patients appreciate these efforts and flexibility. “They’re in a bad situation. As long as we’re willing to work with them, they’re willing to pay us,” Weathers says. “If we said, ‘Sorry you’re in a tough spot, but I’m not going to change our ways,’ then they might say, ‘You’re the last bill I’ll pay, then.’”

Give new patients thorough and clear information about costs. Even before the COVID-19 pandemic, the Proliance surgery centers were successful with benefit and financial counseling before each procedure, Weathers notes.

Not every ambulatory surgery center offers preservice financial counseling, which can be a vital service in good times and bad. “Our more successful centers had a robust process in place and followed that,” Weathers says. “COVID put a wrench in that. But, ultimately, as long as they hold fast and are communicating with patients, then that lets patients drive their care and understand what is going to happen with payment for the procedure, rather than getting a surprise on the back end.”

Patients would rather go into a procedure knowing what is expected of them instead of receiving an unexpected $3,000 bill after surgery. “We verify their benefits and try to come very close to whatever their out-of-pocket is,” Weathers says. “It’s up to each financial representative to educate them and have a thoughtful conversation.”

With thorough information about costs, patients can make a better-informed decision about the procedure and how they might pay for it. For some patients, this might mean they will choose to delay an elective procedure until they are re-employed or can afford the out-of-pocket costs.

“I’ve seen [patients] choose to push their procedure out, hope to be back at work, get medical benefits, and be in a better situation before they have that procedure,” Weathers adds.

Guide patients to alternative insurance. Surgery center staff might need to guide some prospective patients to apply for Medicaid or sign up for coverage through Affordable Care Act exchanges.

“We educate and provide information for patients to get their own insurance through the exchange program,” Weathers says. “Or, if their household is completely out of work, they can apply for Washington state’s Medicaid program.”

Patients often do not know what their options are or how to apply for another type of insurance. “There are resources out there to provide that information so they can feel more empowered to do research and see what the best plan is,” Weathers says. “We can educate and provide them with those resources so they know there are options out there for them.”

The trickiest cases are those in which the patient does not qualify for Medicaid, but earns an income that would make out-of-pocket surgery expenses too costly. “In those cases, we have some charity programs that will allow for extended payment plans,” Weathers adds.

The surgery center’s office staff can provide patients with information, but it is up to patients to complete their applications and take the next step. Unlike hospitals, there are no financial counselors at Proliance surgery centers to review the application process, Weathers notes.

Adjust upfront costs and payment plans for new patients. Surgery centers must use more patience and flexibility as the pandemic continues to disrupt business.

For example, when Proliance patients say they would struggle to come up with a $3,000 upfront payment, a surgery center’s revenue cycle employee might suggest they pay 25% up front, and then pay installments over a longer period. “We’ve seen a fair amount of folks try to negotiate a different out-of-pocket cost and an extended payment plan,” Weathers says.

If a patient selects self-pay because of a lost job and has some savings to pay up front, then the center could offer a discount to make it more affordable. “We were doing that before COVID, and are still doing it after COVID,” Weathers notes.

Encourage staff to show compassion. The pandemic led to a near-halt to all elective surgeries, which in turn led to plenty of surgery center employee furloughs. Those who have returned to work can empathize with patients about what it is like when to lose a job and worry about income.

It is important for revenue cycle staff to keep an open dialogue while trying to work with patients to make payment plans work. “We let our staff know that we don’t know the situation the person who is on the other end of the phone is facing,” Weathers explains. “Fear of surgery is scary enough, and now they have a financial situation where they may not have insurance or have a job. You have to be mindful of that in every call you take.”

The biggest problems are when patients cannot make even a partial payment. Each situation is unique. There can be no cookie-cutter approach to handling these cases. “Every family situation dynamic is different,” Weathers says. “Each individual case has to be reviewed and have someone understand the circumstances behind it.”

A patient might have experienced a worst-case scenario, so it is important for employees to approach each call in the softest manner. “Put yourself in their shoes,” Weathers offers. “When our staff is working with patients, I see a lot more people being compassionate because they’ve been there, they’ve been in the same shoes for the last three months.”


  1. The National Center for Coverage Innovation. The COVID-19 pandemic and resulting economic crash have caused the greatest health insurance losses in American history. July 17, 2020.