Revenue Rx

In this episode of Revenue Rx, we explore one of the most significant hidden threats in healthcare finance: pharmacy revenue leakage. The episode walks backward through the pharmacy revenue cycle, starting with reimbursement and denials management, then moving upstream into coding, charge capture, documentation, and prior authorizations. The discussion highlights how reimbursement is connected to...

The bagging crisis in healthcare is a significant issue that impacts patient care, operational efficiency, and financial sustainability. It involves various models such as brown bagging, white bagging, orange bagging, clear bagging, and gold bagging, each with its own set of challenges and implications. The crisis is not just about drug distribution but also about misaligned incentives, fragmentat...

The podcast discusses the critical role of prior authorizations in determining reimbursement and highlights the importance of understanding the differences in reimbursement processes for pharmacy and medical benefits. It also delves into the definitions of key terms related to prior authorizations, common challenges, ownership, centralized models, and the role of artificial intelligence in reshapi...

This episode dives into the critical operational discipline of charge capture, highlighting the importance of bridging care delivery and reimbursement. It explores the advantages and risks of charge on administration and charge on dispense, emphasizing the impact of mischarges on revenue and the need for reconciliation. We also cover the challenges of charge capture in clinics and the assessment o...

This episode delves into the complexity of drug pricing and the impact of reimbursement on margin. It covers the alphabet soup of drug pricing, WAC, GPO pricing, the 340B program, ASP, AWP, and AAC. Takeaways Complexity of drug pricing Impact of reimbursement on margin Disclaimer This podcast is for informational and educational purposes only. The content shared reflects my personal views and expe...

In this episode, we explore the April 2026 CMS HCPCS quarterly update and its significance for organizations. We delve into the HCPCS transaction file, the Addendum B, and the NDC to HCPCS crosswalk, emphasizing the importance of understanding these files for protecting margins and reimbursement strategies. Takeaways CMS Quarterly Updates are a reimbursement roadmap Understanding the CMS files is...

This episode covers the strategic role of the pharmacy revenue cycle, the operational and financial complexity of pharmacy, and the importance of alignment among pharmacy, revenue cycle, and finance. Takeaways Pharmacy revenue cycle as a strategic driver Aligning pharmacy, revenue cycle, and finance Operational and financial complexity in pharmacy Creating an integrated system for pharmacy revenue...