Nebraska became the first state to implement Medicaid work requirements under HR-1, beginning enforcement May 1, months ahead of the Jan. 1, 2027 deadline most states are now preparing for. For Sheila Augustine, executive director of revenue cycle at Omaha-based Nebraska Medicine, that early timeline was a workflow problem she had to solve in real time.
Nebraska Medicine operates two hospitals, 855 beds and approximately 1,200 physicians, with net patient revenue of roughly $3 billion. Its revenue cycle team has been navigating the disruption that most of the country is still anticipating: patients losing Medicaid coverage, eligibility gaps opening mid-treatment, and the administrative challenge of reaching those patients before they arrive at the point of care.
“We are trying to keep an eye on the people that are losing Medicaid as part of this and get them reenrolled or help to get them on other governmental programs if you can,” Ms. Augustine said.
Her core advice to revenue cycle leaders who have not yet faced this disruption is straightforward. The proactive outreach infrastructure most teams have built around patients who are present or recently discharged is not sufficient. The eligibility problem now starts upstream.
Payer scrutiny has already been intensifying across the industry, and the Medicaid coverage disruptions compound an environment in which denial rates have been climbing for years. Ms. Augustine named denials as the most persistent pressure her team faces alongside Medicaid eligibility — a combination that is straining revenue cycle operations at health systems of every size.
“Every payer — the payers are scrutinizing claims more than they ever have,” she said. “You have to essentially start digging into these payer policies and really trying to combat the denials.”
On the Medicaid side specifically, Ms. Augustine said the most important operational shift is rethinking where eligibility work begins. Teams that have historically focused on patients who are in the building or leaving it need to extend that work to patients who have not yet arrived.
“Can you do essentially some campaigning, right, and reaching out to patients proactively?” she said. “I think we’ve always been worried about the patients while they’re here or after they leave. How can we identify the patients who are coming? And so we can start the work on it now.”
That requires auditing the data already in the EHR. Ms. Augustine said Nebraska Medicine uses Epic and has been evaluating whether it can identify patients flagged as unemployed, a marker that may indicate Medicaid eligibility risk, and initiate outreach before those patients lose coverage or arrive for care without it.
She also flagged staffing capacity as a variable revenue cycle leaders need to assess honestly. The administrative burden of proactive eligibility work is real, and the question of whether to absorb it internally or seek outside support should be asked before the Jan. 1 deadline, not after.
“There could be, depending on the size of the facility — is that an opportunity maybe to outsource, or do you need more staffing to make sure that you can meet those requirements and help patients fill out that application?” she said.
Nebraska’s experience is being watched closely by payers and providers alike as a signal for what the national rollout will look like. Augustine said she anticipates peer organizations will begin reaching out to Nebraska Medicine as the January deadline approaches.
“I do anticipate, you know, places reaching out to us since we did have this already happen to us,” she said.
For revenue cycle teams that have not yet audited their Medicaid eligibility workflows, built proactive outreach capacity or assessed their staffing levels against the coming administrative load, Nebraska Medicine’s early experience suggests that preparation needs to start now, not in December.
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