As the Affordable Care Act (ACA) marketplace premiums climb, physician groups across the country are bracing for more than just shifting insurance markets. In 2026, premiums are projected to rise by a median of 26%, and if premium tax credits are not extended, many enrollees could see their out-of-pocket costs more than double.
These increases have downstream effects across patient behavior, benefit design, payer policies, and ultimately, the revenue cycle. For practice administrators, CFOs, and RCM leaders, understanding how these changes will affect front-end processes, reimbursement, and cash flow is essential.
Below are the key ripple effects physician groups should anticipate and the steps they can take to protect financial stability in 2026.
Short on time? Jump to the key takeaways at the end of this article for a summary of how premium increases may impact your revenue cycle and proactive steps your practice can take.
1. Growing patient financial responsibility
Premium increases frequently go hand-in-hand with higher deductibles, less generous cost-sharing structures, or plan changes that shift more financial responsibility to patients.
What it means for your revenue cycle:
- Higher likelihood of balances being pushed to patient responsibility
- Increased patient A/R and slower collections
- More demand for payment plans and financial counseling
- Greater risk of bad debt write-offs
Operational takeaway:
Front-end teams need strong cost-transparency tools, clear and standardized patient messaging, and ongoing staff training to ensure patient responsibility is communicated accurately and consistently at every touchpoint.
Beyond that, practices can strengthen preparedness by leveraging analytics to identify patients most at risk of self-pay exposure, reviewing historical collection data, and modeling the potential impact of higher deductibles on cash flow. Workflow assessments and automation guidance can help reduce eligibility and billing errors, while strategic planning ensures that financial counseling and payment plan resources are prioritized effectively.
Whether managing these capabilities internally or through a trusted RCM partner, proactively addressing these areas can reduce bad debt, accelerate collections, and maintain patient satisfaction.
As healthcare costs rise, revenue cycle performance is increasingly shaped by how well financial risk is identified and managed early in the patient journey. A preventative, front-end approach focused on accuracy, transparency, and consistent financial communication helps reduce downstream billing issues, improve cash flow predictability, and limits avoidable rework. While these efforts may introduce some additional front-end complexity, they ultimately support a better patient experience and more sustainable financial outcomes as patient financial responsibility continues to grow.
2. Increasing coverage volatility
When premiums rise, many patients shop for cheaper alternatives during open enrollment. This creates a spike in coverage transitions, terminations, and plan switches, which add strain to the revenue cycle.
Impact on physician groups:
- Increased eligibility errors from outdated insurance information
- More claims denied for inactive coverage
- Prior authorization delays due to unfamiliar plan rules
- Surge in staff time spent confirming benefits
Operational takeaway:
Instituting an enhanced insurance verification process will be critical to ensure accurate, up-to-date patient coverage information before services are rendered. Many physician groups without this in-house capability may benefit from partnering with a revenue cycle organization that can provide real-time, automation-driven eligibility verification and coverage detection. These tools lay the foundation for clean claims that result in reduced denials, delays, and costly rework.
In an environment of frequent plan changes and shifting coverage rules, eligibility and benefit information can no longer be treated as static. Re-verifying coverage closer to the point of service helps account for plan changes, reduces eligibility-related denials, and supports cleaner claims. This approach minimizes downstream disruption and promotes more consistent reimbursement outcomes.
Practices that continue to rely on manual checks, on the other hand, are likely to see a significant increase in claim denials, longer reimbursement cycles, and higher administrative burden on staff, which can quickly erode revenue and reduce overall operational efficiency. Without automation, small errors in eligibility or coverage verification can cascade into costly downstream problems that affect both cash flow and patient satisfaction.
3. Rising uninsured and self-pay exposure
For some ACA enrollees, annual premium increases will make coverage unaffordable. One estimate predicts that if enhanced subsidies are not continued, nearly five million Americans could become uninsured in 2026 alone.
Impact on the revenue cycle:
- More self-pay accounts with lower collection probability
- Increased bad debt and write-offs
- Higher demand for charity care or hardship programs
- More payment plan conversations and administrative strain
- Greater financial volatility for physicians serving price-sensitive communities
Operational takeaway:
Practices should strengthen self-pay workflows to help mitigate the financial risk posed by patients who drop coverage due to rising premiums.
Key strategies include providing real-time out-of-pocket calculations so patients understand expected costs before receiving care, offering financial counseling to discuss available discounts and hardship programs, and implementing flexible payment plans to accommodate patients who cannot pay their balances in full upfront.
Having clear discount and charity care policies ensure staff can consistently guide patients toward available support, while a robust call center can proactively manage patient questions, support payment plan enrollment, and follow up on self-pay accounts. Together, these initiatives make it easier for practices to absorb the increase in uninsured patients while maintaining financial stability.
4. Tightening payer controls and policies
When premiums climb, payers often look for ways to manage costs, which can shift financial and administrative pressure onto providers. These adjustments are typically designed to control utilization, limit risk, and ensure that higher plan costs don’t lead to unsustainable payouts.
How payers react:
- Stricter prior authorization requirements
- Narrowed networks and tiered benefit structures
- More medical necessity denials
- Increased documentation demands
Operational takeaway:
Revenue cycle leaders should proactively monitor payer behavior to anticipate shifts in denials, authorization requirements, and documentation expectations.
Leveraging denial analytics and reporting dashboards allows teams to identify patterns by payer and plan type, prioritize high-impact areas, and implement targeted workflow improvements. Practices can also evaluate and refine coding, authorization, and documentation processes to prevent avoidable denials and reduce administrative burden.
Another way to relieve some of the payer policy pressure is to leverage revenue cycle automation. These tools can benefit physician practices by both preventing human errors and freeing staff to focus on higher-value work.
5. Expanding administrative complexity
Premium adjustments often bring new benefit configurations or network changes such as higher deductibles, tiered cost sharing, or narrowed provider panels. These shifts increase administrative tasks across eligibility, billing, and patient communication. For groups already strained by staffing shortages, even small increases in this work can create downstream delays in billing, follow-up, and collections.
Billing teams must navigate:
- More patient questions about coverage
- Higher call volume related to cost estimates and plan details
- Coding and billing edits tied to changing payer rules
- Staff retraining on new documentation requirements
Operational takeaway:
Organizations with standardized training, automated eligibility, and streamlined denial workflows are best positioned to absorb this increased complexity without jeopardizing cash flow.
Beyond these core capabilities, practices can analyze historical data to identify where administrative bottlenecks occur, predict which patients and payers will generate the most questions or rework, and prioritize staff resources accordingly. Workflow assessments and automation guidance can help reduce repetitive tasks, improve coding and billing accuracy, and ensure that follow-up processes remain timely.
By taking a proactive approach to managing administrative burden, organizations can protect both cash flow and patient experience despite the ripple effects of premium shifts.
Key takeaways: premium hikes are an RCM issue
The magnitude of marketplace premium increases is not yet fully known. However, physician groups should plan for ongoing coverage and reimbursement variability under any scenario. Groups that approach these changes proactively – with the right tools, workflows, and training – can maintain financial stability even as patient coverage becomes more volatile.
Revenue cycle leaders who prepare now will be better positioned to reduce friction for patients, prevent denials, and protect reimbursement in the year ahead. Physician groups can take several proactive steps to navigate a shifting landscape:
- Strengthen eligibility verification and use automated tools
Consider automated re-verification for all high-risk encounters – particularly new patients or those with known plan volatility. - Improve financial clearance workflows
Equip front-end staff with messaging scripts, calculators, and training to confidently address high deductibles and out-of-pocket responsibility. - Monitor denial patterns linked to marketplace plans
Identify where payer changes are causing preventable denials and build quick-turn internal guidance for staff. - Invest in patient-friendly payment options
Payment plans, digital statements, and card-on-file options help reduce patient A/R and speed cash flow. - Prioritize staff training on new benefit rules
A brief but targeted refresher can prevent avoidable errors that lead to denials and rework in Q1.
Health Prime can optimize your physician group’s revenue cycle, improve reimbursement, and help support your organization through the changes ahead. To learn more, please send us an email or visit us at hpiinc.com.
