Cleveland Clinic’s controversial new policy: pay copays upfront or lose your appointment

CLEVELAND, Ohio — Starting in June, Cleveland Clinic patients who can’t pay their co-pay on the spot will have nonemergency appointments rescheduled or cancelled, the health system said.

The new policy could make it harder for low-income people who prefer to be billed to see a Clinic doctor, and create delays that could lead to medical emergencies down the road, health policy experts said. A delay in care can mean six to eight more weeks of a tumor growing or a blood clot developing.

“They’re asking the wrong people to pay,” said Alan Sager, professor of health policy and management at the Boston University School of Public Health. “It’s likely that the people who are most vulnerable, medically or financially, will be damaged the most, and that’s a dangerous, unkind and wrong-headed policy.”

The Clinic is the only major area hospital that will cancel or reschedule appointments when patients don’t pay copays upfront.

Starting Sunday, June 1, Clinic patients will be required to pay health insurance copays before appointments, or at check-in, for all nonemergency outpatient services, the health system announced Monday.

The visit will be rescheduled or canceled if a patient cannot make their copay, the Clinic said.

The new policy only applies to nonemergency outpatient services, and does not affect people on Medicaid, the Clinic said.

Rescheduled and canceled appointments could mean a delay of weeks to see a doctor or therapist. The average wait time for a physician appointment for new patients in 15 large U.S. cities was 26 days, up from 20.9 days in 2004, according to a 2022 survey conducted by a physician search firm.

The people who will be most hurt by the new policy are the elderly, people with less money and people with chronic or serious illnesses that require a great number of doctor visits, Sager said.

People who are turned away at the Clinic may show up at MetroHealth or University Hospitals, where the policies are more lenient, Sager said.

“If our common goal is to remove barriers to health care access and improve overall health, this policy moves us away from that goal,” said Charlotte Rudolph, executive director of UHCAN Ohio, a state-based organization addressing health policy issues.

The change in copay policy comes soon after the Clinic again ranked high among U.S. nonprofit hospitals not doing enough to directly benefit their communities, according to the Lown Fair Share 2025 National Report.

The Clinic’s main campus ranked fifth on the Lown Institute’s list of 20 U.S. hospitals doing the worst in community spending, and first place in the state of Ohio. These hospitals have what the institute calls a “fair share deficit,” when hospitals receive more in tax breaks than they give back to the community.

The health system criticized the Lown report because it excluded categories of community benefit that directly impact community health, the Clinic said in a statement. In 2023, the Clinic says it contributed $1.46 billion in community benefit for its operations across Ohio, Florida and Nevada. That included $261 million spent to provide more than 111,000 of its patients with free or discounted medically necessary care.

In 2024, the Clinic generated nearly $16 billion in revenue globally from more than 15 million patient encounters worldwide. However, the health system achieved a profit of only 1.7% of the health system’s overall revenue of $16 billion, falling short of its expectations of an operating margin of 2.7%.

Others in the community feel the area’s large medical systems should do more to support community health. As a candidate for county executive in 2022, Chris Ronayne proposed the creation of a Community Health Equity Fund, which private hospitals like the Clinic and UH would pay into, to help communities provide residents more options for transportation to appointments, create new wellness programs, or bolster mental and physical health services.

The Clinic’s new copay policy affects scheduled office visits; therapy services, outpatient diagnostic testing, and outpatient procedural visits and in-office procedures.

This change doesn’t apply to emergency care, surgeries, inpatient hospital stays or cancer treatments. It also doesn’t apply to urgent or Express Care visits “at this time,” the Clinic said.

It’s not uncommon for patients to have a medical emergency uncovered during a routine doctor visit, Rudolph said. “If someone puts off seeing the doctor because they can’t afford the copay because they don’t get paid for a week or two, there would be a delay in treating an unknown infection or other serious illnesses, which could make their condition worse.”

A copay is a fixed dollar amount a patient must pay for a doctor’s visit, lab test or prescription, as part of their health insurance plan. Copay amounts are determined by the insurance plan and can vary depending on the healthcare service rendered.

About 10% of respondents to a KFF 2023 Employee Health Benefits Survey said they had a copayment for outpatient hospital services, while 47% had a copay for emergency room visits.

Patients should contact their insurance provider for information on copay requirements for their plan, including the expected cost and which services require them, the Clinic said.

Efficiency is reason behind change

It’s more efficient to collect copays before or at the time of service, the Clinic said in a statement.

“Collecting all patient financial responsibility for the care we provide, starting with copays, helps us ensure sustainable hospital operations and supports the seamless delivery of care,” the health system said.

The medical system did not directly address cleveland.com’s questions about how the new policy will affect patient access to care.

Before the change, some Clinic patients opted to have their copays billed instead of paying before or at the time of their appointment.

From the hospital’s standpoint, after-the-fact billing that requires reminders to be mailed out is costly, Sager said.

The U.S. healthcare system include co-pays because policy experts think the payments force people evaluate whether they really need the care, Sager said.

In reality, most people are not well informed about their health and need a primary care physician to evaluate their problem, Sager said.

Other hospital’s policies surrounding co-pays

UH requests co-pays for elective services in advance, either at the time of scheduling the visit or during check-in. However, UH does not cancel or reschedule appointments if the co-pay is not paid ahead of time, the medical system said.

“We strongly encourage patients to pay their co-pays up front,” UH said in a statement. “This helps confirm the accurate amount early in the process and reduces the likelihood of receiving a bill later, which we understand can sometimes be confusing.”

Akron’s Summa Health makes every effort to collect copayments at the time of service, however it is not a requirement in order to proceed with the appointment, Summa said. If payment cannot be collected at the time of service, Summa Health accepts partial payments or will issue a bill afterwards.

At MetroHealth, patients can ask to have their copay billed to insurance.

Julie Washington covers healthcare for cleveland.com. Read previous stories at this link.