Doctors and hospitals increasingly are asking insured patients to pay more of their bills for elective procedures at the time of the service, rather than collecting a small fee and waiting until later to get the rest of what's owed.
Earlier collection helps avoid payment delays and bad debt, experts say, but also raises concerns for consumers.
"I think the new aggression on the part of providers to collect payments reflects the growing cost of health care and their need to stay financially viable," said Sara Collins, vice president at the Commonwealth Fund, an independent foundation that supports research on improving the U.S. health care system.
But, she added: "From a consumer standpoint, I think it's a very ominous development for patients. The trends in employer-based coverage, and most people have that, is towards ever-increasing levels of out-of-pocket exposure."
Hospitals and physician practices say they are under greater financial pressure to get payment for the services they provide, and can't easily do what they have historically done: collect a token copayment upfront, perform the procedure, then sit back and wait for insurers to run the numbers and for patients to pay them.
Insurance is covering less, and if patients don't pick up the rest, providers are stuck holding the debt.
With unpaid medical debt in the tens of billions of dollars and rising, and with the number of high-deductible plans increasing, the issue is causing stress and potentially affecting care.
"Even people with six-figure salaries can have trouble paying a $5,000 deductible," said Dr. Douglas Lundy, the co-president for Georgia-based Resurgens Orthopaedics. "People are choosing not to do tests or surgery. The high deductibles are hurting things."
The growth in high-deductible plans and increasing bad debt are closely related, said Michael Mascolo, north region employee benefits practice leader for Wells Fargo Insurance. Providers used to have very few people in these plans, but that has changed. More employers are offering high-deductible plans, and workers are signing up for them because they offer lower premiums. The high-deductible plans save employers money and can mean lower premiums for employees.
The number of workers with high-deductible plans that included a health savings account option jumped to 20 percent of all covered workers last year, from 5 percent in 2007, according to the Kaiser Family Foundation.
Kaiser said 1 in 3 Americans has had problems paying medical bills in the last year, is paying old bills over time, or has bills that can't be paid at all.
As a result, Mascolo said, there is "an explosion of bad debt."
American hospitals provided $41 billion in uncompensated care in 2011, according to the American Hospital Association. That includes "bad debt" for services that hospitals expected to be paid for but were not, and charity care.
"We're being flooded with patients with little or no ability to pay their portion of the bill," said Greg Hurst, chief operating officer for Piedmont Healthcare. About 50 percent of its patients are on a high-deductible plan with some form of co-insurance, he said.