Why Patient Financial Responsibility Needs Our Full Attention

If you’ve read the headlines lately you may have seen that the payer paradigm, especially for Medicare Advantage plans, is shifting beneath our feet. A recent Wall Street Journal article reports that “insurers are planning to scale back benefits, trim plans and exit from markets.” How precisely this will manifest is yet to be seen, but what used to be “smart business” is about to become “table stakes” for orthotics and prosthetics viability. 

We’re accustomed to working within the boundaries of the healthcare payers and plans. But the second half of 2025 may bring a more daunting reality: insurers are slashing their Medicare Advantage offerings. The Journal reports that more than a million Medicare beneficiaries may be forced to change their coverage and insurers have dialed back their Advantage plans by over 6%. While most practices are probably thankful that there may be fewer Medicare Advantage plans to suck you dry, the flipside for the patient might be greater out of pocket expenses. 

Medicare Advantage plans must set an annual limit on how much a beneficiary can be asked to pay for covered services. For 2025, this in-network “max out-of-pocket” can be up to $9,350 (most plans set it lower, around $5,000), after which the plan covers 100% of Part A and B expenses for the rest of the year. However, Original Medicare (Part B) has no out-of-pocket maximum. Under Part B, after an annual deductible ($240 in 2025), beneficiaries are responsible for 20% of the Medicare Allowable. 

Historically, discussing finances with patients was a sidebar, squeezed between a benefits verification check and the start of a clinical intervention. That approach no longer suffices. Our benefits conversations must now become risk assessments and, frankly, a form of patient advocacy. If you’re not verifying and looking for benefit changes at the first point of scheduling, the likelihood your patients are surprised by unexpected bills climbs with every passing week. 

It’s not enough to ask, “Has your insurance changed?” We must proactively walk patients through what exactly is covered, what isn’t, and which new hurdles might appear. Providing a clear, honest picture early in the care journey transforms uncomfortable financial conversations into collaborative planning. The patient isn’t simply being “processed;” they’re being prepared—and protected—from the system’s shifting tides. 

Where high-deductible patients once comprised only a slice of our caseload, now nearly every Medicare and Medicare Advantage recipient is at risk of feeling financial strain. As costs rise and coverage continues to narrow, patient responsibility needs to move from back-office options to front-line tools.  

For returning patients, especially those caught in the crosswinds of changing coverage (“But this was covered last year!”), I recommend having straightforward protocols for “coverage transitions.” Be transparent, be empathetic, and above all, be proactive. The last thing a patient needs is another surprise. 

There is positive movement in Washington, such as the O&P Patient-Centered Care Act, (Click on that link to  ask your legislators to support the Act) which promises to distinguish our services from DME and streamline administrative barriers. Yet, as anyone who’s followed insurance reforms knows, change at that level comes at a pace far slower than what our patients and businesses demand. 

At the practice level, now’s the time to revisit your insurance contracting strategy. Relying too heavily on any given Medicare Advantage plan is a risk as insurers reduce benefits or exit local markets. Diversification and contingency planning aren’t just nice to have; they form the foundation for resilience. 

Ultimately, your financial communication and flexibility are as vital as fitting, fabrication, and follow-up. Payment plans and patient advocacy are not mere business practices; they are critical pathways to restored lives. 

Change is certain. The question is, how will your clinic respond? Practices that choose transparency over ambiguity, advocacy over bureaucracy, and planning over panic will find they can support their patients—and their business—even in an era of uncertainty. The future belongs to those who are ready, willing, and able to adapt. Let’s make sure we’re leading, not lagging, in this new reality.