Orthopaedic Patient Collections in 2026: How to Collect Before Surgery, Ahead of the Q4 Surge and the January Deductible Reset

Orthopaedic patient collections improve when the practice treats the patient's share as a pre-service task rather than a post-service bill. That means verifying benefits and remaining deductible before surgery is scheduled, giving the patient a specific estimate, collecting a deposit or setting a payment plan before the date of service, and reconciling the balance within days of the payer's remittance.

It matters more in orthopaedics than in almost any other specialty, because surgical balances are large, they cluster in the fourth quarter when patients have met their deductibles, and they reset in January when those same deductibles start over. National data shows the problem is getting worse: according to Kodiak Solutions, patient responsibility rose to 7.3 percent of provider net revenue in 2025, while the collection rate on that patient share fell from 45.1 percent to 42.4 percent.

This guide covers the numbers behind the shift, the calendar pattern specific to orthopaedics, the federal rules that govern estimates, and a pre-service collections workflow a group with five or more surgeons can put in place before the year-end surge.

Why patient balances are a bigger orthopaedic problem every year

Three forces are pushing more of every orthopaedic dollar onto the patient.

Deductibles are high, and more workers face $2,000 or more. The 2025 KFF Employer Health Benefits Survey puts the average general annual deductible for single coverage at $1,886. Eighty-eight percent of workers with single coverage have a deductible, and 34 percent of covered workers have one of $2,000 or more, up from 32 percent in 2024. At firms with 10 to 199 workers, that figure is 53 percent. One-third of covered workers are enrolled in a high-deductible plan with a savings option.

Federal limits keep climbing. Under IRS Revenue Procedure 2026-24, the minimum HDHP deductible rises to $1,750 for self-only coverage and $3,500 for family coverage in 2027, and the HDHP out-of-pocket maximum rises to $8,700 and $17,400. On the ACA marketplace, CMS set the 2027 maximum annual limitation on cost sharing at $12,000 for self-only coverage, up from $10,600 in 2026. Medicare Part B patients face a $283 deductible in 2026, up from $257 in 2025, before the 20 percent coinsurance on surgical services.

Orthopaedic procedures hit the deductible and then some. A 2022 study in the Journal of the American Academy of Orthopaedic Surgeons using commercial claims found mean out-of-pocket costs of $2,733 for total knee arthroplasty and $2,884 for total hip arthroplasty, with costs rising for every procedure studied and the highest burden on HDHP enrollees. Those figures cover the full episode, and the professional component is only one piece, but they show why the surgeon's bill is often the one that arrives after the patient has already paid the hospital or surgery center.

The result is an accounts receivable mix that looks healthy on the payer side and quietly deteriorates on the patient side. In a January 2026 MGMA Stat poll, practice leaders named denials and appeals as their biggest revenue cycle leak, but patient balances rarely show up in denial reporting, which is exactly why they get missed.

The orthopaedic calendar: Q4 surge, January reset

Orthopaedic surgical volume is seasonal, and deductibles are a large part of why.

A 2026 study in the Journal of Arthroplasty found that among patients with high cost sharing, 35.7 percent of total knee arthroplasties were performed in the fourth quarter, compared with 30.8 percent among patients with average cost sharing. An earlier analysis in the Annals of Medicine and Surgery reported average orthopaedic surgical volume rising 38 percent from January to December across 2016 to 2019, and research on lumbar fusion found surgery more likely in Q4 than Q1.

That pattern creates two distinct collection problems.

October through December: volume rises and many patients have met or nearly met their deductibles, so the patient balance per case is often lower, but the number of cases is higher and staff are stretched. Balances that are small per patient still add up, and they get deprioritized.

January through March: deductibles reset. A patient who owed a few hundred dollars for a December arthroscopy can owe several times that for the identical procedure in February. Practices that did not verify remaining deductible at scheduling discover this when the explanation of benefits arrives, weeks after the patient has gone home.

Both problems have the same fix: know the patient's remaining deductible and out-of-pocket status at the time of scheduling, and re-verify within a few days of surgery, because a patient's accumulator can change between those dates.

Why collecting after the visit fails

MGMA benchmarking cited in an October 2025 MGMA Stat analysis shows time-of-service collection of patient-due balances rising from about 15 percent in 2019 to 39 percent in 2022, which means more practices are moving collections forward. That October 2025 poll also found 29 percent of practices said patient balance collections got worse in 2025 compared with 2024, and only 26 percent said they improved.

The practices that are falling behind tend to share three habits:

1. Estimates are generic. A range based on a fee schedule rather than the patient's actual benefits is easy to produce and easy for the patient to ignore.
2. Statements are the first contact. By the time a paper statement arrives, the patient has recovered, moved on, and may already be disputing charges with the facility.
3. Collections referral waits too long. In a December 2022 MGMA Stat poll, 42 percent of practices waited 91 to 120 days before sending accounts to collections and 32 percent waited more than 120 days. Aging data from outside healthcare suggests receivables lose much of their collectability over that window.

Patients want a different experience. In Experian Health's 2025 State of Patient Access survey, 81 percent of consumers said an accurate estimate helps them prepare financially, and 43 percent said they would postpone or cancel care without one. In J.P. Morgan's 2026 healthcare payments trends report, 58 percent of consumers said they would switch providers for a better payment experience.

What the No Surprises Act requires

Federal rules already set a floor for estimates, and orthopaedic groups should make sure their workflow meets it.

Uninsured and self-pay patients must receive a good faith estimate. Under 45 CFR 149.610, a provider must deliver the estimate within one business day of scheduling when the service is scheduled at least three business days out, within three business days of scheduling when the service is scheduled at least ten business days out, and within three business days of a patient's request. The estimate must list the expected items and services with codes and expected charges.

Patients can dispute large variances. Under 45 CFR 149.620, a self-pay patient can start the patient-provider dispute resolution process if the final bill is at least $400 more than the good faith estimate, within 120 calendar days of receiving the initial bill. While the dispute is pending, the provider cannot move the bill to collections or charge late fees.

The insured patient estimate is still pending. The Advanced Explanation of Benefits and the related good faith estimate for insured patients have not been enforced since 2022, and HHS reaffirmed that deferral in December 2024. The HHS 2026 regulatory agenda lists Advanced EOB rulemaking, but no rule was in effect as of this writing. Practices that build accurate insured patient estimates now will be ready when it arrives, and in the meantime they will collect more.

For self-pay surgical patients, the estimate needs to account for the surgeon's professional fee, the assistant surgeon if applicable, anesthesia, and the facility. The codes on the estimate should match what will actually be billed, which is a coding accuracy problem as much as a front office one.

A pre-service collections workflow for orthopaedic surgery

This workflow is designed for groups with five or more surgeons and a centralized surgery scheduling team.

Step 1: Verify at scheduling, not at check-in

Run a real-time eligibility and benefits check when the surgery is booked. Capture the plan's remaining deductible, coinsurance percentage, out-of-pocket maximum remaining, and whether prior authorization is required. For a Q4 case booked in August, re-verify within a week of the date of service.

Step 2: Build the estimate from the expected codes

Estimate from the CPT codes, modifiers, and units the surgeon is actually expected to bill, including multiple procedure payment reductions and bilateral rules. A total knee estimate that ignores an expected assistant surgeon claim, or an arthroscopy estimate that assumes two procedures pay at 100 percent, will be wrong and will generate the kind of variance that damages trust.

Step 3: Have the conversation before surgery

Give the patient the estimate in writing and walk through it by phone or at the preoperative visit. Explain what is included, what is not (facility and anesthesia are usually billed separately), and what happens if the procedure changes intraoperatively.

Step 4: Collect a deposit or set a plan

Set a clear policy: for example, collect the estimated patient share, or a defined percentage of it, before the date of service, and offer a written payment plan for balances above a threshold. Experian's 2026 survey found 63 percent of patients would feel more confident with tailored payment plans. Make the policy consistent across surgeons, since patients compare notes and front office staff need a rule, not a judgment call.

Step 5: Reconcile within days of the remittance

When the ERA posts, compare actual patient responsibility to the estimate and the deposit. Refund overpayments promptly, and send a digital statement for any remaining balance immediately. Every week a balance sits unbilled lowers the chance of collecting it.

Step 6: Segment the follow-up

Treat a $150 balance on a patient with a card on file differently from a $2,500 balance on a patient without one. Automate reminders for small balances, and route large balances to a person who can set up a plan.

Know the rules before sending accounts to collections

Collections policy has shifted. The CFPB finalized a rule in January 2025 to remove medical debt from credit reports, but a federal court in Texas vacated it in July 2025. The three national credit bureaus still voluntarily exclude paid medical collections, unpaid medical debt less than one year old, and medical collections under $500, and roughly 15 states have their own medical debt reporting laws. For most orthopaedic balances, credit reporting is no longer meaningful leverage. That makes the pre-service steps above more valuable, not less.

Metrics to track

• Point-of-service collection rate: patient payments collected at or before the date of service as a share of total patient payments.
• Patient responsibility collection rate: cash collected on patient balances divided by patient responsibility posted, tracked monthly and by payer class.
• Estimate variance: the gap between estimated and actual patient responsibility. Large variances point to benefit verification or coding problems.
• Days to first statement: time from remittance posting to the first patient statement.
• Patient A/R over 90 days: as a share of total patient A/R.

HFMA's MAP Keys provide standardized definitions for several of these, which helps when comparing across sites after a merger or PE platform roll-up.

Frequently asked questions

When should an orthopaedic practice collect the patient's share for surgery?‍

Before the date of service whenever possible. Verify benefits and remaining deductible when the surgery is scheduled, re-verify close to the surgery date, give the patient a written estimate, and collect a deposit or set a payment plan beforehand. Reconcile against the payer's remittance as soon as it posts.

What is the average deductible patients face in 2026?‍

The most recent KFF Employer Health Benefits Survey (2025) reports an average general annual deductible of $1,886 for single coverage, with 34 percent of covered workers facing a deductible of $2,000 or more. The Medicare Part B deductible is $283 in 2026.

Do orthopaedic practices have to give patients a good faith estimate?‍

Yes for uninsured and self-pay patients under the No Surprises Act. The estimate must be provided within one to three business days depending on how far out the service is scheduled, and a patient can dispute a bill that exceeds the estimate by $400 or more. The requirement for insured patients has not yet been enforced.

Why do orthopaedic surgery volumes rise in the fourth quarter?‍

Research in the Journal of Arthroplasty found patients with high cost sharing are more likely to have total knee arthroplasty in Q4, consistent with patients scheduling elective surgery after meeting their annual deductible. The reverse happens in January, when deductibles reset and patient balances per case jump.

Can unpaid medical bills still be reported to credit bureaus?‍

The CFPB rule that would have banned it was vacated in July 2025. However, the national credit bureaus voluntarily exclude paid medical collections, medical debt less than a year old, and balances under $500, and some states restrict reporting further. Practices should confirm their state rules and collection agency practices.

How does coding accuracy affect patient collections?‍

Directly. The patient's share is calculated from the codes, modifiers, and units billed. If the estimate is built from different codes than the claim, or the claim is denied and rebilled, the patient receives a bill that does not match what they were told, and collection rates drop.

Where Maia fits

Patient collections start with a clean claim. When CPT codes, modifiers, and diagnoses are right the first time, the remittance arrives faster, the patient's share is calculated correctly, and the statement matches the estimate. Maia's AutoCoder recommends and populates codes and clinical justification inside the EHR before a human coder touches the chart, and Maia's Collections and Contracting tools help orthopaedic groups find the money they already earned. Orthopaedic groups today.

See how Maia supports orthopaedic practices. Book a demo at usemaia.com.