Revenue Rx

How did Medicare and Medicaid evolve into one of the most influential forces shaping healthcare reimbursement? In this episode of Revenue Rx, we explore more than 60 years of healthcare policy, from the creation of Medicare and Medicaid in 1965 to prospective payment systems, Medicare Part D, and modern drug pricing reform. Discover how these milestones shaped pharmacy reimbursement, hospital fina...

CMS has finalized the GLOBE Model, introducing international drug pricing benchmarks for select Medicare Part B drugs. But the final rule looks significantly different from the original proposal. In this episode of Revenue RX, Lubna Mazin breaks down what changed, how reduced patient coinsurance affects provider reimbursement, and what pharmacy revenue cycle, finance, and patient financial service...

The 340B Rebate Model Pilot Program begins January 1, 2027, bringing significant changes to how covered entities access 340B savings. In this episode, we break down the 10 participating manufacturers, 22 affected drugs, rebate timelines, claims requirements, and financial implications of moving from upfront discounts to retrospective rebates. Learn how this shift impacts cash flow, reconciliation,...

The October 2026 CMS HCPCS Quarterly Update brings more than a routine list of new and deleted codes. This quarter includes major changes to billing units, manufacturer-specific HCPCS codes, new oncology and biosimilar codes, revised descriptions, and at least one discrepancy between a CMS coding determination and the published quarterly file. Update: J0014 Cocaine hydrochloride nasal solution (Go...

Medicare reimbursement changes throughout the year through annual rulemaking, quarterly updates, ASP files, HCPCS changes, and new effective dates. In this episode of Revenue RX, we walk through the CMS reimbursement calendar month by month so pharmacy, finance, and revenue cycle teams know when to audit claims, model proposed changes, prepare for final rules, and validate builds before payment is...

Submitting an appeal is easy. Submitting an appeal that actually addresses why a claim was denied is a different skill. In this episode of Revenue RX, we break down the pharmacy appeals process from both a reimbursement and financial perspective. We start with one of the most important decisions: determining whether a denial requires a corrected claim, reconsideration, or formal appeal. We discuss...

Fixing a denied claim is not the same as fixing the problem that caused it. In this episode of Revenue RX, we explore how pharmacy revenue cycle teams can move beyond individual claim resolution and build a closed-loop process that prevents recurring denials, underpayments, and reimbursement gaps. We break down how to identify root causes, route issues to the right operational owners, correct upst...

Denial rate alone does not tell the full story of revenue cycle performance. Before a claim can be fixed, teams need to correctly diagnose what actually happened: Was it rejected before adjudication, denied after adjudication, underpaid, paid at zero, or only partially paid? In this episode of Revenue RX, we break down the operational differences between rejections and denials and explain how Clai...

In this episode of Revenue RX, the focus is on the key performance indicators that matter most across the pharmacy revenue cycle. From front-end authorization and financial clearance to charge capture, denials, underpayments, write-offs, and financial performance, the discussion breaks down how teams can use KPIs to identify risk and drive action. The episode also explains why not every metric des...

CMS’s proposed CY 2027 340B policy could change more than reimbursement. It could change how acquisition decisions, billing modifiers, and drug margin interact. In this episode of Revenue RX, we break down the proposed return of the JG modifier as a payment-triggering modifier, the continued use of TB for certain exempt 340B drugs and providers, and CMS’s proposed new XX modifier for drugs acquire...

This episode breaks down how to build an effective team around a complex healthcare function, from identifying the work that needs to be done to determining the right roles, reporting structure, and timing for new hires. The discussion explores how to map responsibilities, avoid common organizational mistakes, and create a team structure that supports both operational execution and long-term growt...

Pass-through status is not a one-time CMS classification. It is a constantly moving pipeline, with new drugs entering protected payment status while others transition into standard OPPS reimbursement. In this episode of Revenue RX, we use the July 1, 2026 OPPS updates as a real-world case study to break down what changed and what pharmacy revenue cycle teams should be watching. We cover newly code...

Every HCPCS code billed under the Outpatient Prospective Payment System (OPPS) is assigned a status indicator. But what do those letter designations mean for reimbursement? In this episode of Revenue RX, we explore how CMS uses OPPS status indicators to determine payment methodology for outpatient services, drugs, biologics, and vaccines. Learn the difference between separately payable, packaged,...

In this episode of Revenue RX, we discuss why the NDC/HCPCS crosswalk serves as the "Rosetta Stone" of pharmacy billing, translating the language of pharmacy (NDCs) into the language of medical billing (HCPCS codes). Takeaways Understand the purpose of the NDC/HCPCS Crosswalk and why it is essential for pharmacy billing. Learn why NDC-to-HCPCS relationships are at times many-to-one or one-to-many...

Description CMS has proposed one of the most significant changes to 340B reimbursement since the Supreme Court's 2022 decision in American Hospital Association v. Becerra. In this special episode of Revenue RX, we break down the Calendar Year 2027 Hospital Outpatient Prospective Payment System (OPPS) proposed rule and explain what it could mean for hospitals participating in the 340B Drug Pricing...

Modifiers may be only two characters long, but they can make or break a claim. In this episode of Revenue RX, we explore why modifiers are like adjectives, adding the context that completes the story behind a claim. Learn about JW and JZ, the latest 340B modifier changes, modifiers for routes of administration, ESA and ESRD billing, and common mistakes that can lead to denials, payment delays, and...

Revenue codes are one of the foundational elements of hospital billing, yet they are often misunderstood. In this episode of Revenue RX, we discuss what revenue codes are, how they function on the UB-04 claim form, and why they play an important role in pharmacy reimbursement. The episode walks through the four primary pharmacy revenue code ranges, 025X, 026X, 063X, and 089X, explaining what each...

What if the UB-04 claim form wasn't just a collection of boxes and billing codes, but an epic story? In this episode of Revenue RX, we reimagine the institutional claim form as a journey through a medieval kingdom. The patient becomes the hero, the hospital becomes the storyteller, and the payer becomes the king deciding whether the story deserves a bag of gold. Along the way, we explore how every...

Healthcare reimbursement has a language all its own. In this episode of Revenue RX, we break down the essential reimbursement terminology that drives healthcare finance and pharmacy revenue cycle management. Whether you're new to revenue cycle or looking to strengthen your financial acumen, this episode provides a foundational understanding of the acronyms, coding structures, and payment concepts...

A practical walkthrough of the revenue cycle ecosystem and how each team contributes to moving care from access to payment. This episode explains the roles of managed care, preaccess, pharmacy, clinical teams, revenue integrity, IT, HIM, coding, patient financial services, finance, and compliance, and why pharmacy leaders need to understand the full process. Takeaways Revenue cycle success depends...

The podcast explores the July 2026 HCPCS coding updates and their impact on pharmacy revenue cycle operations. It reviews new drug and biosimilar HCPCS codes, deleted and reinstated codes, CMS's continued approach to 505(b)(2) products, and newly established administration codes. The episode emphasizes the operational importance of timely code implementation, reimbursement readiness, and cross-fun...

The podcast explores how pharmacy revenue cycle leaders can use the midpoint of the year to evaluate financial performance, identify reimbursement risks, and strengthen operational processes before entering the second half of the year. The episode walks through five critical assessments that can help organizations improve reimbursement integrity, reduce revenue leakage, and prepare for upcoming fi...

The podcast delves into the operational significance of the 835 remittance advice file in pharmacy revenue cycle management. It emphasizes the importance of understanding and leveraging the 835 file for reimbursement integrity, operational intelligence, and financial sustainability. Takeaways Operational Significance of the 835 File Leveraging Remittance Data for Reimbursement Integrity Chapters 0...

In this week's episode, we dive into the different claim pathways used to bill medications, including NCPDP D.0 for pharmacy benefits, 837P for professional claims, and 837I for institutional claims. Takeaways Different claim pathways for medication billing Understanding the impact of claim pathways on reimbursement and operational workflows Chapters 00:00 Introduction to Pharmacy Revenue Cycle Ma...

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...