By Johnathen Worth, MBA, Principal, Vestra Tribal Care
Every Tribal health program we work with is being asked to do more with less. Providers are stretched, referrals are expensive, and IHS funding rarely keeps pace with need. That makes third-party revenue from Medicaid, Medicare, and private insurance one of the few levers a Tribe controls directly, and those collections go back into care for the community.
In our experience, programs rarely lose revenue through one big failure. They lose it quietly, a little at a time, across thousands of visits. Here are the five places we look first, plus a Medicaid change taking effect January 1, 2027 that makes the first one more urgent.
1. Patients who qualify for coverage but are not enrolled
Many patients who come through the door are eligible for Medicaid, Medicare, or Marketplace coverage but have never enrolled, or have let coverage lapse. When that happens, the visit is paid from the program’s own funds, and specialty care may fall to Purchased and Referred Care (PRC).
What changes on January 1, 2027. Under the federal budget law passed in 2025 (H.R. 1), retroactive Medicaid coverage gets shorter. For the Medicaid expansion group it drops from three months to one month, and for most other groups from three months to two. The state guidance we reviewed does not list an exemption for American Indian and Alaska Native patients on this change. A program that used to enroll a patient weeks after a visit and still get paid may now miss that window.
What to do:
Screen for coverage at every visit, not only at new patient visits.
Make a benefits coordinator or application assister part of check-in, not an afterthought.
Track enrollment as a front desk measure each week.
Know your state’s process for documenting Native status. American Indians and Alaska Natives are exempt from the new Medicaid work requirements, and certain American Indian and Alaska Native individuals are exempt from the new six-month renewals for expansion adults. Your state Medicaid agency decides how that status is recorded, so make sure staff can help patients use it.
2. Visits that never become claims, or are billed at the wrong rate
Depending on how the facility is enrolled and which payer is involved, many Tribal and IHS facilities are paid at the IHS all-inclusive rate (often called the OMB or encounter rate), which is published each year in the Federal Register. That rate only helps when the facility is enrolled correctly with each payer and every encounter is documented and billed the way that payer requires.
We regularly find visits that never became a claim, encounters billed on a fee schedule when the encounter rate applied, and separately billable services that were never billed. One simple habit catches most of this: each week, reconcile every scheduled and walk-in visit against a submitted claim.
3. Denials that no one has time to work
A denied claim is not lost money until the filing deadline passes. In smaller programs, the billing team often has time to submit claims but not to follow up. A short weekly denial review, sorted by reason and dollar amount with an owner for each category, is one of the fastest places to recover revenue. Over time, the denial reasons also show you which front end problems to fix.
4. New providers seeing patients before payer enrollment is complete
Recruiting a provider to a rural Tribal clinic is hard work, and it is tempting to get them in front of patients right away. If a provider sees patients before enrollment with a payer is complete, those visits may not be billable to that payer. Start enrollment and credentialing the day an offer is accepted, track each provider’s status by payer, and plan schedules around it.
5. Pharmacy claims and referred care that coverage could pay for
Prescriptions filled in-house for patients with coverage can usually be billed to that coverage. If your pharmacy fills for insured patients without billing, that is revenue the program has already earned.
Referred care matters too. Federal regulations make PRC the payer of last resort, which means other available coverage has to be used first. Every patient enrolled in coverage stretches PRC dollars further for the patients who have no other option. And under CMS guidance from 2016, states can receive 100 percent federal Medicaid funding for certain care that outside providers deliver to American Indian and Alaska Native patients under written care coordination agreements with IHS or Tribal facilities. That gives your state a reason to partner with you on referrals.
Where to start
Finding these dollars does not require a large project. Start here:
Pull 12 months of visit counts, claims, payments, and denials.
Compare visits to claims, and claims to payments, by month and by payer.
Check how many patients at check-in had no coverage on file, and how many were screened.
Pick the two largest gaps and assign an owner and a date to each.
If you would like a second set of eyes, we are glad to help. Vestra’s 30-Day Focused Assessment looks at exactly these areas and gives your leadership a clear written report with estimated financial impact and practical next steps, with no commitment beyond that first step.
This article is general education, not legal or billing advice. Rules vary by state and payer, so confirm details with your state Medicaid agency and Tribal counsel.
About Vestra Tribal Care. Vestra Tribal Care is a Native-owned, clinician-led healthcare consulting and management company that works with Tribes exclusively. We help Tribes build, expand, and optimize their healthcare systems. We strengthen what you already have. We don’t replace it.
Sources
Nebraska DHHS, Tribal H.R. 1 Timeline (accessed October 26, 2026): dhhs.ne.gov/Documents/Tribal%20H.R.1%20Timeline.pdf
Virginia DMAS, H.R. 1 Medicaid Eligibility Changes (accessed October 26, 2026): dmas.virginia.gov
CMS State Health Official Letter #16-002, Federal Funding for Services Received Through IHS/Tribal Facilities (February 26, 2016): medicaid.gov/federal-policy-guidance/downloads/SHO022616.pdf
42 CFR 136.61, Payor of last resort (Purchased and Referred Care)
