Two things happen to a medical practice's revenue every December and January, and both are predictable. In December, patients who have met their deductible for the year try to fit in procedures, imaging and follow-ups before the clock resets, and the practice collects well because the payer pays most of the allowed amount. In January, every deductible resets, the practice performs the same services, and a large share of the allowed amount becomes patient responsibility that arrives weeks later or never.
The numbers for 2025 are already public. CMS announced on November 8 that the Medicare Part B deductible rises to $257 from $240, with the standard Part B premium at $185. Commercial deductibles keep climbing; a high-deductible health plan needs a deductible of at least $1,650 for self-only coverage in 2025 under the IRS thresholds, and many employer plans sit well above that. A practice that treats December and January as ordinary months leaves money in both.
Key takeaways
- The 271 eligibility response already tells you each patient's remaining deductible; split the December schedule into met, nearly met and unmet, and act differently on each.
- Offer met-deductible patients with pending orders a December appointment; it is better for them and for the practice.
- Estimates fail on the first input, the codes likely to be billed. Build them from your own claims history by visit type, not from the scheduled visit level.
- January collection order: time of service, card on file, text or portal link, paper statement last.
- Size the January cash dip from last year's numbers so payroll and vendor payments are planned, not surprised.
Start with the report you already have
Every eligibility response your practice receives (the 271 transaction, the payer's answer to the 270 inquiry) contains the patient's deductible and the amount remaining, for in-network benefits, at the time of the check. Most practice management systems store it. Few practices report on it. Pull the eligibility data for every patient on the schedule between now and December 31 and split them into three groups:
- Deductible met. The patient owes a copay or coinsurance only. These are the patients who benefit from completing planned care in December, and the practice benefits from performing it now rather than in January.
- Deductible nearly met. A remaining balance below the cost of the planned service. The patient will pay part of the service and the payer will pay the rest.
- Deductible largely unmet. The patient will owe most of the allowed amount for anything done this year, and the same again in January. For these patients the question is not when to schedule but how to collect.
If the system cannot produce this report, that is a finding in itself. The data has been arriving on every eligibility check for years, and a practice that cannot see it is estimating blind.
Scheduling with the deductible in view
Practices sometimes feel awkward about this, and we think that is misplaced. A patient with a met deductible who has a knee injection, a colonoscopy referral or a sleep study pending is better served by being offered a December appointment, and most will say yes when the front desk explains why. Have the scheduler review the pending orders list for met-deductible patients each week from now to mid-December, and call them. The volume this creates in the last two weeks of December is worth planning provider schedules around; a provider who usually takes the week between Christmas and New Year off may want to reconsider one of those days.
For patients with unmet deductibles and elective work, the honest conversation is the reverse: the cost to them is the same in December and January, so schedule on clinical need and on their preference, and give them an estimate either way. Some will prefer January because a new flexible spending account year starts; that is their call.
Estimates that hold up
A good estimate needs three inputs: the CPT codes likely to be billed, the contracted allowed amount for each with that payer, and the patient's remaining deductible and coinsurance from the eligibility response. Most estimating failures come from the first input. The front desk estimates a 99213 and the provider bills a 99214 with a procedure. Build estimates from what the provider actually bills for that visit type; your own claims history for the last 12 months is the best source, and it takes an afternoon to summarize the top ten visit types per provider.
| Input | Source | Common error |
|---|---|---|
| Likely CPT codes | Claims history by appointment type and provider | Estimating the visit, forgetting the procedure or the lab |
| Allowed amount | Contracted fee schedule for that payer | Using the charge instead of the allowed amount |
| Remaining deductible | 271 eligibility response, checked within 48 hours of the visit | Using a check from the last visit two months ago |
| Coinsurance | Eligibility response or plan summary | Assuming a copay applies when the plan uses coinsurance |
| Out-of-pocket maximum | Eligibility response | Collecting a deductible from a patient who has already hit the maximum |
Write the estimate down, give it to the patient, and record it in the account. When the claim adjudicates, compare. If your estimates are within 10% of the actual patient responsibility most of the time, the front desk can collect against them with confidence. If they are not, fix the inputs before you push collection harder; a front desk that has been embarrassed by a wrong estimate twice will stop asking.
Collect at the time of service, and make paying easy afterwards
January is when time-of-service collection matters most, because the patient responsibility is large and the payer portion is small. Three practices make the difference:
- Ask for the estimated amount at check-in, not the copay. A patient with an unmet deductible has no copay in the usual sense; the visit is deductible. The script is "Your plan applies today's visit to your deductible. Based on your benefits the estimate is $148. Would you like to take care of that today?"
- Offer a card on file with a cap. Written consent to charge the card for the adjudicated patient responsibility up to a stated maximum, with a receipt sent when it happens. Patients accept this more often than practices expect, and it removes the statement cycle for most balances.
- Turn on online payment and the portal, and actually promote it. Practices that have a patient portal with payment enabled and never mention it collect little through it. The ones that put a QR code on the statement, send a text with a payment link when the statement posts, and let the front desk enroll patients at checkout see a meaningful share of balances paid within days. Patients pay a $148 balance from a phone at 9 p.m.; they don't mail a check for it.
The order matters. Time of service first, card on file second, portal and text link third, paper statement last. A paper statement should be the fallback, not the plan.
The January cash dip, and how to size it
Take last January's payments and compare them with last December's. For most practices the January payer receipts fall and the patient AR rises by a similar amount, and the gap closes over February and March. The size of that gap is your deductible exposure. Knowing it lets you plan payroll and vendor payments instead of being surprised, and it tells you what better collection would be worth.
| Month | Payer receipts | Patient receipts | New patient AR created | Total cash |
|---|---|---|---|---|
| December 2023 | $262,000 | $31,000 | $28,000 | $293,000 |
| January 2024 | $214,000 | $34,000 | $81,000 | $248,000 |
| February 2024 | $226,000 | $52,000 | $64,000 | $278,000 |
| March 2024 | $241,000 | $58,000 | $47,000 | $299,000 |
In this example the practice's cash fell $45,000 from December to January while the patient balances it created nearly tripled. Some of that patient AR is collected in February and March; some of it, historically around a fifth in practices we have reviewed, never is. Collecting even half of January's new patient AR at the time of service would have made January an ordinary month. That is the number to put in front of the owners when the front desk asks why the script matters.
Medicare-heavy practices should also remember that the first Medicare claim processed in January absorbs the $257 Part B deductible, and the first claim processed is not always the first service performed. Submitting January claims promptly is the only lever you have on that.
Mistakes we see
Treating a deductible visit as a copay visit. The front desk collects $30 and the practice statements $118 three weeks later, at which point the patient has forgotten the visit.
Estimating from charges. The patient is quoted $320, the allowed amount is $148, and the patient does not trust the next estimate either.
Statements on a monthly batch. A balance that adjudicates on January 6 and reaches the patient on February 1 is already old. Statement on adjudication, weekly at most.
Ignoring the remaining-deductible field. The single most useful number in the eligibility response, and the one most practices never look at.
Collecting from patients who have met the out-of-pocket maximum. Rare in January, common in December, and a refund every time.
Questions we hear
Is it appropriate to call met-deductible patients and suggest a December appointment?
Yes, for care that is already ordered or recommended. You are telling the patient something true about their own benefits and offering them a choice. It is not appropriate to order services because the deductible is met, and providers should not be asked to.
What if the estimate is wrong and we collected too much?
Refund it promptly and say so. Set a rule: any credit balance over a small threshold is refunded within two weeks of adjudication without the patient asking. A practice that refunds quickly earns the right to ask for estimates at check-in.
Can we require payment before the visit?
For elective services with a written estimate, many practices collect a deposit at scheduling and the balance at check-in, and payer contracts generally allow collection of the patient's cost share. Emergency or urgent care is different, and Medicare and Medicaid have their own rules on what can be collected and when. Check your contracts and ask counsel before writing a policy that refuses service for non-payment.
What to do this month
- Pull the eligibility data for the December schedule and split patients into met, nearly met and unmet deductible.
- Have the scheduler review pending orders for met-deductible patients each week through mid-December and call them.
- Build estimate templates for your top ten visit types per provider from your own claims history.
- Confirm the portal payment feature is switched on, that statements carry the link or a QR code, and that a text goes out when a statement posts.
- Write the January check-in script and the card-on-file consent, and train both in the second week of December.
- Build the four-month cash table above from last year's numbers and show the owners the January gap.
- If the practice does not have the reporting to do the first step, the Revelrex RCM audit includes patient collection performance, the billing service runs statements on adjudication with payment links, and practices that want a portal built into their website can see the website development service.
