Revenue Rx

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...

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...