One Big Beautiful Bill Act (OBBBA)

Preparing Your Healthcare Organization for the One Big Beautiful Bill Act: Strategic Guidance for Revenue Cycle Excellence

The healthcare landscape is shifting dramatically following the enactment of the One Big Beautiful Bill Act (OBBBA) in July 2025. This landmark legislation brings nearly $1 trillion in Medicaid funding cuts over the next decade, stricter eligibility requirements beginning in 2026, and changes to Medicare reimbursement and ACA insurance subsidies. For healthcare organizations operating on already thin margins—especially those serving radiology, anesthesiology, hospitalist services, and rural healthcare communities—the path forward requires strategic planning, technological innovation, and compassionate patient financial engagement.

The Financial Impact: What Healthcare Leaders Should Know

The Congressional Budget Office projects that up to 11.8 million Americans could lose Medicaid coverage as a result of OBBBA. An additional 4.2 million people covered under ACA marketplace plans would become uninsured with the expiration of enhanced premium tax credits on December 31, 2025. For healthcare providers, these coverage losses translate into a surge of self-pay patients, rising uncompensated care costs, and significant revenue volatility.

According to the Waystar Advisory Board—comprising healthcare financial leaders from organizations of varying sizes—79% identified Medicaid coverage as their top concern, while 42% cited both ACA marketplace coverage and increased patient financial responsibility as critical challenges. When asked about margin impacts, 48% of board members expect moderate margin declines of 6-10% by fiscal year 2028, while 30% anticipate small declines of 1-5%. Without strategic intervention, these financial headwinds could devastate provider organizations.​

The impact extends beyond individual providers. Research shows that Medicaid currently accounts for nearly one-fifth (19%) of healthcare and hospital funding. Rural areas face disproportionate challenges, with Medicaid covering 23% of rural Americans compared to 19% nationally—and roughly half of all rural children. Analysis from the Urban Institute estimates rural hospital revenue could drop by $87 billion over ten years, with uncompensated care in rural areas increasing by an estimated $23 billion.

Understanding the Coverage Crisis: Medicaid and ACA Changes

The OBBBA implements Medicaid funding cuts gradually, with some restrictions taking effect immediately and others phased in over the next five years. Enhanced ACA premium tax credits—which have helped millions afford marketplace coverage since 2021—expire December 31, 2025. Without congressional extension, subsidized enrollees would see their annual premium payments more than double, rising 114% from an average of $888 in 2025 to $1,904 in 2026.medicarerights+3​

For middle-income enrollees above 400% of the federal poverty level, the impact is even more severe. A 60-year-old couple making $85,000 would see yearly premium payments rise by over $22,600 in 2026, bringing their benchmark plan cost to about a quarter of their annual income. These dramatic increases will likely drive many patients to drop coverage entirely, creating a cascade of challenges for healthcare providers.kff​

The uncompensated care burden will be substantial. The Urban Institute estimates that total uncompensated care demand would increase by $7.7 billion (12% relative to baseline) if enhanced premium tax credits expire. This burden falls disproportionately on already-struggling safety-net hospitals and rural providers. Research demonstrates that rural hospitals already carry higher uncompensated care rates than urban facilities (3.81% vs. 3.12%), with the gap even more pronounced in non-Medicaid expansion states (6.28% for non-expansion vs. 2.55% for expansion states).urban+2​

Strategic Response: Three Pillars for Revenue Cycle Resilience

Healthcare organizations must adopt a multi-pronged approach to navigate the OBBBA landscape successfully. Based on insights from the Waystar white paper and supplemented by current industry research, three strategic pillars emerge as essential.

1. Create Clarity Through Intelligent Eligibility Verification

The traditional approach of checking eligibility only at registration is no longer sufficient. As eligibility requirements tighten and coverage shifts become more frequent, healthcare organizations must implement continuous, automated verification throughout the entire revenue cycle.​

Modern eligibility verification technology can transform this process. Automated systems verify coverage in real-time—often in under 30 seconds—by connecting directly to insurance databases through APIs and clearinghouses. Organizations using intelligent automation platforms have uncovered correct insurance information for 58% of accounts that initially had incorrect or no coverage listed, with no manual effort required.practolytics+1​

The Council for Affordable Quality Healthcare (CAQH) estimates that fully automating eligibility verification and eight other common revenue cycle transactions could save the U.S. healthcare system $16.3 billion annually. For individual organizations, automation can save 10 minutes per eligibility check, adding up to hundreds of hours annually for midsize clinics.auxis+1​

Robotic Process Automation (RPA) takes this further by acting as tireless digital assistants that log into insurance portals, retrieve patient coverage details, and update EHR systems 24/7 without human intervention. Hospitals using RPA have reported saving up to 60% of administrative time while boosting accuracy.practolytics​

For organizations specializing in hospital-based services like radiology and anesthesiology—where coverage verification complexity is heightened—automated eligibility systems integrated with EMR and hospital information systems provide the flexibility needed to adapt quickly to OBBBA’s evolving requirements.​

2. Strengthen Claims Management and Denial Prevention

With reimbursement pressures mounting from Medicare adjustments and declining Medicaid rates, maximizing clean claim submission becomes critical. The American Medical Association reports that between 1.38% and 5.07% of claims are denied on first submission. Even well-performing practices experience denial rates around 5%, representing significant administrative burden and revenue leakage.the-rheumatologist​

Proactive denial prevention strategies deliver superior results compared to reactive denial management. Pre-claim scrubbing technology analyzes claims line-by-line before submission, catching common errors like missing data and incorrect codes. Organizations implementing AI-driven claims management have reduced denial rates from 12% to 3.5%, recovering millions in revenue while cutting administrative overhead by 40%.experian+2​

Machine learning algorithms can predict potential denials by analyzing historical data and identifying patterns, enabling preemptive corrections before submission. Real-time eligibility verification tools prevent denials caused by coverage lapses or plan changes, while automated prior authorization management systems ensure timely approvals for high-cost treatments.finthrive+1​

For rural healthcare (RHC) billing specialists and providers working with multiple payer types across varied specialties, flexible, in-house revenue cycle software offers distinct advantages. Custom-built systems can quickly adapt to changing payer policies, integrate seamlessly with EMR and hospital systems for data transfers, and provide the agility needed to respond to OBBBA’s evolving landscape.​

3. Enhance Patient Financial Engagement with Compassion and Technology

As patient financial responsibility increases dramatically under OBBBA, healthcare organizations must balance collections effectiveness with compassionate care. The key lies in leveraging technology to make the payment experience transparent, convenient, and personalized.​

Modern patient financial engagement platforms offer multiple digital payment channels—including text-to-pay, mobile pay, online portals, and Apple Pay/Google Pay integration—that align with patient preferences. Research shows that 68% of patients prefer to pay medical bills electronically, and organizations using digital payment solutions see point-of-service payment increases of 30% or more. Organizations collecting payments through patient engagement platforms report that more than 80% of patients pay their copays at the time of service.waystar+1​​

AI-powered propensity-to-pay modeling segments patients by their likelihood and capacity to pay, enabling tailored outreach strategies. For families facing financial hardship, extended payment plans and automated charity care screening identify those who qualify for financial assistance programs early, maintaining goodwill while preventing futile billing efforts.auxis​​

Text statements represent a particularly effective innovation. Patients can view bills, make payments, and set up personalized payment plans directly from their smartphones, increasing collections by 10-30% while dramatically reducing paper statement and postage costs.upfronthealthcare+1​

For providers serving diverse patient populations across specialties like mental health, family practice, and OB-GYN—where patient volumes are high and financial situations vary widely—automated patient financial engagement tools reduce staff burden while improving the patient experience.auxis​​

Sector-Specific Considerations: Protecting Vulnerable Providers

The OBBBA’s impact will not be distributed evenly. Rural hospitals and providers face particularly acute challenges. Research from the University of Michigan shows that roughly 80% of rural hospital closures since the Affordable Care Act have occurred in states that failed to expand Medicaid. Currently, over 300 rural hospitals face immediate risk of closure even before the OBBBA cuts take effect.sph.umich​

While Congress approved a $50 billion Rural Health Transformation Fund to address Medicaid shortfalls, this funding represents only about 37% of the estimated $137 billion in federal Medicaid spending cuts to rural areas over ten years. The program’s effectiveness remains uncertain, as specific distribution criteria and eligibility requirements have not yet been clearly defined.pbs+2​

For hospital-based physician services—including radiology, anesthesiology, and hospitalist groups—the OBBBA creates unique challenges. These specialties typically encounter patients during acute episodes when insurance verification may be incomplete or outdated. Emergency department encounters involving uninsured patients have already increased in states experiencing Medicaid coverage disruptions. Continuous eligibility monitoring and automated coverage detection become essential capabilities for these providers.schoolofpublichealth.washu​​

Urban safety-net hospitals also face significant threats. Among the 109 acute care hospitals deemed most vulnerable to OBBBA’s cuts, 85% are urban facilities serving predominantly low-income populations. These organizations must balance increased uncompensated care demands against declining reimbursement, making revenue cycle optimization not just a financial imperative but an existential necessity.fiercehealthcare​

Building Financial Resilience: Technology as the Foundation

The healthcare organizations best positioned to thrive in the post-OBBBA environment share common characteristics: they invest in flexible, intelligent revenue cycle technology; they automate repetitive tasks while empowering staff for high-value work; and they use data-driven insights to anticipate and adapt to policy changes.wns+1​​

In-house software development provides distinct competitive advantages for organizations navigating OBBBA’s complexity. Custom-built systems offer the flexibility to quickly adapt to regulatory changes, seamlessly integrate with diverse EMR and hospital information systems, and efficiently handle specialty-specific billing requirements for radiology, anesthesiology, hospitalist services, and rural healthcare programs. This agility becomes increasingly valuable as state-by-state Medicaid variations and payer-specific policy changes create a fragmented compliance landscape.​

Cloud-based revenue cycle platforms with AI and machine learning capabilities enable real-time tracking, predictive analytics, and automated workflows that transform multi-step processes into transparent, highly effective operations. Analytics deployment is expected to reduce U.S. healthcare administrative spending by $360 billion, with nearly 90% of financial analytics predicted to be fully automated by 2027.wns​

For practices concerned about implementation complexity, modern revenue cycle platforms integrate with existing systems with minimal disruption, providing real-time updates and automated end-of-day reconciliation. The investment pays dividends through increased staff satisfaction—as employees move from tedious manual tasks to meaningful patient interactions—improved cash flow, and enhanced financial stability.phreesia+3​

The Path Forward: Action Steps for Healthcare Leaders

Healthcare organizations should take immediate action across several key areas to prepare for OBBBA’s implementation:

Conduct comprehensive financial modeling. Develop multi-year forecasts through 2034 that account for Medicaid funding reductions, ACA subsidy expiration, and potential Medicare reimbursement changes. Model various scenarios for payer mix shifts and uncompensated care increases specific to your patient population and geographic market.​

Audit current revenue cycle processes. Identify manual bottlenecks, measure eligibility verification accuracy, calculate current denial rates, and assess patient payment collection efficiency. These baseline metrics enable measurement of improvement as new systems are implemented.experian+1​

Prioritize technology investments. Implement or upgrade automated eligibility verification systems with continuous monitoring capabilities, AI-powered claims management and denial prevention tools, patient financial engagement platforms with multiple digital payment options, and integrated analytics dashboards for real-time visibility.practolytics+1​​

Strengthen workforce capabilities. Provide ongoing training on changing payer policies and OBBBA provisions, implement standardized documentation protocols, and invest in staff development programs that emphasize both technical skills and compassionate patient financial counseling.finthrive+1​

Expand financial assistance programs. Review and update charity care policies to reflect increased patient need, implement automated screening for financial assistance eligibility, and develop flexible payment plan options with clear, patient-friendly communication.pdcflow​

Monitor policy developments closely. Track state-specific Medicaid implementation timelines, follow congressional debates on ACA premium tax credit extension, and maintain awareness of Medicare reimbursement formula adjustments. Adaptive organizations adjust strategies proactively rather than reactively.tax.thomsonreuters​

Conclusion: Opportunity Within Challenge

The One Big Beautiful Bill Act presents undeniable challenges to healthcare financial performance. Coverage losses, reimbursement pressures, and rising uncompensated care will test organizational resilience across the industry. Yet within these challenges lie opportunities for innovation, optimization, and competitive differentiation.

Organizations that embrace intelligent automation, flexible technology platforms, and patient-centered financial engagement will emerge stronger. Those that continue relying on manual processes, reactive denial management, and fragmented systems will struggle to maintain financial viability.

For medical billing and revenue cycle management companies specializing in hospital-based physician services and rural healthcare—with in-house software systems that provide unmatched flexibility and integration capabilities—the OBBBA era represents a moment to demonstrate value. By helping provider organizations navigate complexity, optimize revenue capture, and deliver compassionate patient financial care, these specialized partners become essential to healthcare’s sustainable future.

The path forward requires strategic vision, technological investment, and unwavering commitment to both financial excellence and patient care. Healthcare organizations that act decisively today will not merely survive the OBBBA transition—they will thrive in the healthcare landscape it creates.

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This analysis draws upon the Waystar white paper “Navigating the One Big Beautiful Bill Act: Implications for the Healthcare Revenue Cycle + Actions Leaders Should Take Now” and incorporates current research on Medicaid funding, ACA premium tax credits, uncompensated care trends, revenue cycle automation, and healthcare financial strategies.

Key Sources:

• Congressional Budget Office OBBBA Impact Analysisupdates.apaservices​

• KFF Analysis: ACA Marketplace Premium Impactskff​

• Urban Institute: Uncompensated Care Projectionsurban​

• Council for Affordable Quality Healthcare: RCM Automation Benefitsauxis​

• Rural Hospital Uncompensated Care Researchpmc.ncbi.nlm.nih​