<![CDATA[Revenue Rx]]>Revenue Rx is a podcast at the intersection of pharmacy and finance, designed to simplify the complexities of pharmacy revenue cycle management.

Hosted by Lubna Mazin, PharmD, MS, 340B ACE a pharmacy leader with experience across health system operations, specialty pharmacy, and revenue cycle strategy, this podcast breaks down the systems that drive reimbursement, margin, and patient access.

From drug pricing and payer dynamics to CMS updates and high-cost therapies, each episode translates real-world challenges into practical insights you can actually use.

Whether you are new to pharmacy revenue cycle or deep in the work, Revenue Rx is your space to connect the dots, build confidence, and stay ahead in a rapidly evolving landscape.

Healing patients is the mission. Protecting the margin is the strategy. This is Revenue Rx.

]]>https://riverside.comRiverside.fm (https://riverside.com)Sun, 14 Jun 2026 12:26:31 GMTMon, 13 Apr 2026 21:46:11 GMT60Lubna Mazin<p>Revenue Rx is a podcast at the intersection of pharmacy and finance, designed to simplify the complexities of pharmacy revenue cycle management.</p><p></p><p>Hosted by Lubna Mazin, PharmD, MS, 340B ACE a pharmacy leader with experience across health system operations, specialty pharmacy, and revenue cycle strategy, this podcast breaks down the systems that drive reimbursement, margin, and patient access.</p><p></p><p>From drug pricing and payer dynamics to CMS updates and high-cost therapies, each episode translates real-world challenges into practical insights you can actually use.</p><p></p><p>Whether you are new to pharmacy revenue cycle or deep in the work, Revenue Rx is your space to connect the dots, build confidence, and stay ahead in a rapidly evolving landscape.</p><p></p><p>Healing patients is the mission. Protecting the margin is the strategy. This is Revenue Rx.</p>episodicLubna Mazinlubna1mazin@gmail.comno<![CDATA[ 🚨 July 2026 CMS HCPCS Quarterly Update 🚨]]>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-functional coordination to prevent denials, underpayments, and revenue leakage following the July 1 go-live.

Takeaways

  • Understanding the July 2026 HCPCS Coding Updates
  • Preparing Revenue Cycle Operations for July 1 Go-Live
  • Evaluating New Biosimilar Reimbursement Implications
  • Understanding CMS 505(b)(2) Billing Methodology Changes
  • Operationalizing New Drug Administration Codes
  • Reducing Revenue Leakage Through Proactive Readiness Assessments

Chapters

00:00 CMS July 2026 Updates
01:38 New HCPCS Codes
03:14 Biosimilar Additions
04:38 Deleted and Reinstated Codes
05:57 Understanding 505(b)(2) Products
06:08 Impact of 505(b)(2) Products on Reimbursement
06:44 New M-Codes and Administration Billing
08:21 Are You Ready for Go-Live?
09:31 Disclaimer

References

Centers for Medicare & Medicaid Services. (2026). HCPCS quarterly update July 2026 coding decisions. U.S. Department of Health and Human Services. https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update

Centers for Medicare & Medicaid Services. (2026, April 8). MLN Matters MM14470: July 2026 HCPCS quarterly update. U.S. Department of Health and Human Services. https://www.cms.gov/files/document/mm-14470-vaccine-administration-national-fee-schedule-july-2026-quarterly-update.pdf

Disclaimer

This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.

]]>059e37ba-5ca4-49e3-93f6-9dce8c42df78Mon, 08 Jun 2026 10:00:00 GMT<p>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-functional coordination to prevent denials, underpayments, and revenue leakage following the July 1 go-live.</p><p></p><p>Takeaways</p><ul><li>Understanding the July 2026 HCPCS Coding Updates</li><li>Preparing Revenue Cycle Operations for July 1 Go-Live</li><li>Evaluating New Biosimilar Reimbursement Implications</li><li>Understanding CMS 505(b)(2) Billing Methodology Changes</li><li>Operationalizing New Drug Administration Codes</li><li>Reducing Revenue Leakage Through Proactive Readiness Assessments<p></p></li></ul><p>Chapters</p><p>00:00 CMS July 2026 Updates<br />01:38 New HCPCS Codes<br />03:14 Biosimilar Additions<br />04:38 Deleted and Reinstated Codes<br />05:57 Understanding 505(b)(2) Products<br />06:08 Impact of 505(b)(2) Products on Reimbursement<br />06:44 New M-Codes and Administration Billing<br />08:21 Are You Ready for Go-Live?<br />09:31 Disclaimer</p><p></p><p>References</p><p>Centers for Medicare &amp; Medicaid Services. (2026). <i>HCPCS quarterly update July 2026 coding decisions</i>. U.S. Department of Health and Human Services. <a rel="noopener noreferrer nofollow" href="https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update" target="_blank">https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update</a></p><p>Centers for Medicare &amp; Medicaid Services. (2026, April 8). <i>MLN Matters MM14470: July 2026 HCPCS quarterly update</i>. U.S. Department of Health and Human Services. <a rel="noopener noreferrer nofollow" href="https://www.cms.gov/files/document/mm-14470-vaccine-administration-national-fee-schedule-july-2026-quarterly-update.pdf" target="_blank">https://www.cms.gov/files/document/mm-14470-vaccine-administration-national-fee-schedule-july-2026-quarterly-update.pdf</a></p><p></p><p>Disclaimer</p><p>This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.</p>no00:09:5811 🚨 July 2026 CMS HCPCS Quarterly Update 🚨full<![CDATA[The Pharmacy Revenue Cycle Mid-Year Checklist]]>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 fiscal and regulatory changes.

Takeaways

  • Evaluating Mid-Year Financial Performance
  • Identifying Denial Trends and Reimbursement Risks
  • Improving Charge Capture and Revenue Integrity
  • Assessing Underpayment Opportunities
  • Measuring Prior Authorization Effectiveness
  • Reviewing Aging Accounts Receivable
  • * Preparing for the Second Half of the Fiscal Year

Chapters

00:00 Introduction: Why June Matters

01:33 Financial Performance Review

02:48 Denials Analysis

04:14 Charge Capture and Missing Revenue

06:13 Underpayment Analysis

07:39 Prior Authorization Performance

09:08 Aging Accounts Receivable

09:52 Finding Risk Before Year-End

11:02 Disclaimer

Disclaimer

This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.

]]>1f5966c4-6401-4075-bea4-309b14a994b1Mon, 01 Jun 2026 10:00:00 GMT<p>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 fiscal and regulatory changes.</p><p></p><p>Takeaways</p><ul><li>Evaluating Mid-Year Financial Performance</li><li>Identifying Denial Trends and Reimbursement Risks</li><li>Improving Charge Capture and Revenue Integrity</li><li>Assessing Underpayment Opportunities</li><li>Measuring Prior Authorization Effectiveness</li><li>Reviewing Aging Accounts Receivable</li><li>* Preparing for the Second Half of the Fiscal Year</li></ul><p></p><p>Chapters</p><p>00:00 Introduction: Why June Matters</p><p>01:33 Financial Performance Review</p><p>02:48 Denials Analysis</p><p>04:14 Charge Capture and Missing Revenue</p><p>06:13 Underpayment Analysis</p><p>07:39 Prior Authorization Performance</p><p>09:08 Aging Accounts Receivable</p><p>09:52 Finding Risk Before Year-End</p><p>11:02 Disclaimer</p><p></p><p>Disclaimer</p><p>This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.</p><p></p>no00:07:5610The Pharmacy Revenue Cycle Mid-Year Checklistfull<![CDATA[The 835 File: Where Claims Turn Into Cash]]>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

  • 00:00 835 Remittance Advice
  • 01:47 Breaking Down the 835
  • 05:46 Utilizing the 835 to Improve Performance

Disclaimer

This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.

]]>071224d2-fdee-4923-ab7c-79e5223b6216Mon, 25 May 2026 10:00:00 GMT<p>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.</p><p></p><p>Takeaways</p><ul><li>Operational Significance of the 835 File</li><li>Leveraging Remittance Data for Reimbursement Integrity</li></ul><p></p><p>Chapters</p><ul><li>00:00 835 Remittance Advice</li><li>01:47 Breaking Down the 835</li><li>05:46 Utilizing the 835 to Improve Performance</li></ul><p></p><p>Disclaimer</p><p>This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.</p>no00:08:319The 835 File: Where Claims Turn Into Cashfull<![CDATA[One Drug, Three Billing Pathways]]>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 Management

01:08 Pharmacy Benefit Claims: NCPDP D.0

04:05 Medical Benefit Claims: 837P

05:23 Medical Benefits Claim: 837I

06:10 Takeaway

08:08 Disclaimer

Disclaimer

This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, reimbursement, compliance, or operational advice. Always consult your internal compliance, legal, finance, and revenue cycle teams before implementing any strategy discussed in this episode.

]]>1885c98b-c063-49ec-aa0b-b56f93bcec0eMon, 18 May 2026 10:00:00 GMT<p>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.</p><p></p><p>Takeaways</p><ul><li>Different claim pathways for medication billing</li><li>Understanding the impact of claim pathways on reimbursement and operational workflows</li></ul><p></p><p>Chapters</p><p>00:00 Introduction to Pharmacy Revenue Cycle Management</p><p>01:08 Pharmacy Benefit Claims: NCPDP D.0</p><p>04:05 Medical Benefit Claims: 837P </p><p>05:23 Medical Benefits Claim: 837I</p><p>06:10 Takeaway</p><p>08:08 Disclaimer</p><p></p><p>Disclaimer</p><p>This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, reimbursement, compliance, or operational advice. Always consult your internal compliance, legal, finance, and revenue cycle teams before implementing any strategy discussed in this episode.</p><p></p><p></p>no00:08:368One Drug, Three Billing Pathwaysfull<![CDATA[Every Breath You Take, Revenue is at Stake]]>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 every handoff, workflow, click, and documentation requirement across the healthcare system. Small operational failures can create major downstream financial consequences, including denials, underpayments, compliance exposure, and permanent revenue loss.

Takeaways

  • Revenue leakage is often caused by small operational breakdowns that compound across the revenue cycle.
  • Denials management requires structured workflows, clear escalation pathways, and ongoing follow-up.
  • Strong pharmacy revenue cycle management depends on cross-functional collaboration across clinical, financial, and operational teams.
  • High-performing organizations use denials and reimbursement trends to improve workflows upstream.

Chapters

  • 00:00 Introduction to Revenue Leakage
  • 01:21 Reimbursement & Denials
  • 04:16 Billing, Coding & Charge Integrity
  • 05:52 Documentation & Medical Necessity
  • 06:58 Prior Authorizations & Financial Risk
  • 08:18 The Importance of Cross-Functional Collaboration
  • 09:24 Disclaimer

Disclaimer

This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.

]]>274f5e78-c487-4c92-9a9c-35b55b17bd4bMon, 11 May 2026 10:00:00 GMT<p>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.</p><p></p><p>The discussion highlights how reimbursement is connected to every handoff, workflow, click, and documentation requirement across the healthcare system. Small operational failures can create major downstream financial consequences, including denials, underpayments, compliance exposure, and permanent revenue loss.</p><p></p><p>Takeaways</p><ul><li>Revenue leakage is often caused by small operational breakdowns that compound across the revenue cycle.</li><li>Denials management requires structured workflows, clear escalation pathways, and ongoing follow-up.</li><li>Strong pharmacy revenue cycle management depends on cross-functional collaboration across clinical, financial, and operational teams.</li><li>High-performing organizations use denials and reimbursement trends to improve workflows upstream.</li></ul><p></p><p>Chapters</p><ul><li>00:00 Introduction to Revenue Leakage</li><li>01:21 Reimbursement &amp; Denials</li><li>04:16 Billing, Coding &amp; Charge Integrity</li><li>05:52 Documentation &amp; Medical Necessity</li><li>06:58 Prior Authorizations &amp; Financial Risk</li><li>08:18 The Importance of Cross-Functional Collaboration</li><li>09:24 Disclaimer</li></ul><p></p><p>Disclaimer</p><p>This podcast is intended for informational and educational purposes only. The views expressed are personal opinions and do not represent those of any employer or affiliated organization. This content does not constitute legal, financial, compliance, reimbursement, or clinical advice. Healthcare regulations, payer policies, and reimbursement requirements vary by organization and jurisdiction. Always consult your internal compliance, legal, finance, revenue cycle, and operational teams before implementing any strategy discussed in this episode.</p>no00:09:497Every Breath You Take, Revenue is at Stakefull<![CDATA[The Bagging Crisis]]>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, fragmentation, and the ability of health systems to sustain high-cost, high-complexity care.

Takeaways

  • Bagging crisis impacts patient care, operational efficiency, and financial sustainability
  • Different bagging models have unique challenges and implications

Chapters

  • 00:00 Introduction to the Bagging Crisis
  • 00:34 Patient Impact
  • 02:08 Impacted Therapies
  • 03:46 Buy & Bill
  • 04:35 Brown Bagging
  • 05:22 White Bagging
  • 06:01 Orange Bagging
  • 07:20 Clearbagging
  • 09:27 Gold Bagging
  • 12:07 DIsclaimer

Links

Vizient Survey on the Patient Care Impact and Additional Expense of White/brown Bagging

ASHP White-Bagging Infographic

Asembia Specialty Pharmacy Drive-by Model

Disclaimer

This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>fa31dca5-5d4b-4b69-8484-db4a896c1e10Mon, 04 May 2026 11:50:33 GMT<p>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, fragmentation, and the ability of health systems to sustain high-cost, high-complexity care.</p><p></p><p><b>Takeaways</b></p><ul><li>Bagging crisis impacts patient care, operational efficiency, and financial sustainability</li><li>Different bagging models have unique challenges and implications</li></ul><p></p><p><b>Chapters</b></p><ul><li>00:00 Introduction to the Bagging Crisis</li><li>00:34 Patient Impact</li><li>02:08 Impacted Therapies</li><li>03:46 Buy &amp; Bill</li><li>04:35 Brown Bagging</li><li>05:22 White Bagging</li><li>06:01 Orange Bagging</li><li>07:20 Clearbagging</li><li>09:27 Gold Bagging</li><li>12:07 DIsclaimer</li></ul><p></p><p><b>Links</b></p><p><a rel="noopener noreferrer nofollow" href="https://vizientinc-delivery.sitecorecontenthub.cloud/api/public/content/e91a7583f7554888ba4031786e5f1430" target="_blank"><b>Vizient Survey on the Patient Care Impact and Additional Expense of White/brown Bagging</b></a></p><p><a rel="noopener noreferrer nofollow" href="https://www.ashp.org/-/media/assets/advocacy-issues/docs/White-Bagging-Infographic.pdf" target="_blank"><b>ASHP White-Bagging Infographic</b></a></p><p><a rel="noopener noreferrer nofollow" href="https://www.managedhealthcareexecutive.com/view/the-mainstreaming-of-cell-and-gene-therapy-and-what-that-means-for-price-distrubtion-asembia-axs26-summit" target="_blank"><b>Asembia Specialty Pharmacy Drive-by Model</b></a></p><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:12:356The Bagging Crisisfull<![CDATA[From Authorization to Payment: Strengthening the Front End of Revenue Cycle]]>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 reshaping prior authorization workflows.

Takeaways

  • Prior authorizations are critical for determining reimbursement
  • Understanding the different reimbursement processes for pharmacy and medical benefits is essential

Chapters

  • 0:02 Introduction
  • 1:05 Why Prior Authorizations Matter
  • 2:16 Pharmacy vs. Medical Benefits
  • 3:53 Key Terms Defined
  • 6:08 Where Organizations Go Wrong
  • 8:57 High-Performing Organizations & AI
  • 11:13 Disclaimer

Links

2024 AMA Prior Authorization Physician Survey

Disclaimer

This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>5255a619-b94a-4fbd-a79b-e3703bf7becbMon, 27 Apr 2026 10:30:00 GMT<p>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 reshaping prior authorization workflows.</p><p></p><p><b>Takeaways</b></p><ul><li>Prior authorizations are critical for determining reimbursement</li><li>Understanding the different reimbursement processes for pharmacy and medical benefits is essential</li></ul><p></p><p><b>Chapters</b></p><ul><li>0:02 Introduction</li><li>1:05 Why Prior Authorizations Matter</li><li>2:16 Pharmacy vs. Medical Benefits</li><li>3:53 Key Terms Defined</li><li>6:08 Where Organizations Go Wrong</li><li>8:57 High-Performing Organizations &amp; AI</li><li>11:13 Disclaimer</li></ul><p></p><p><b>Links</b></p><p><a rel="noopener noreferrer nofollow" href="https://www.ama-assn.org/system/files/prior-authorization-survey.pdf" target="_blank">2024 AMA Prior Authorization Physician Survey</a></p><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:18:005From Authorization to Payment: Strengthening the Front End of Revenue Cyclefull<![CDATA[You Can’t Bill What You Don’t Capture: The Hidden Gaps in Pharmacy Revenue]]>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 of medication areas and waste capture.

Takeaways

  • Charge capture is a critical operational discipline that bridges care delivery and reimbursement.
  • Charge on administration (COA) aligns revenue with patient care, while charge on dispense (COD) aligns revenue with operational activity.
  • Clinics are a major source of silent leakage due to low volume and visibility.
  • Reconciliation is a crucial part of charge capture, comparing what was purchased, dispensed, administered, and billed.

Disclaimer

This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>ee44feca-8659-4e22-bcce-e00110d0ebabMon, 20 Apr 2026 14:54:50 GMT<p>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 of medication areas and waste capture.</p><p></p><p><b>Takeaways</b></p><ul><li>Charge capture is a critical operational discipline that bridges care delivery and reimbursement.</li><li>Charge on administration (COA) aligns revenue with patient care, while charge on dispense (COD) aligns revenue with operational activity.</li><li>Clinics are a major source of silent leakage due to low volume and visibility.</li><li>Reconciliation is a crucial part of charge capture, comparing what was purchased, dispensed, administered, and billed.</li></ul><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:10:094You Can’t Bill What You Don’t Capture: The Hidden Gaps in Pharmacy Revenuefull<![CDATA[Drug Pricing Explained: The Numbers That Drive Margin]]>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 experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>d3f8e5aa-e433-4007-9e48-6cf763659d2cMon, 13 Apr 2026 21:56:19 GMT<p>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.</p><p></p><p><b>Takeaways</b></p><ul><li>Complexity of drug pricing</li><li>Impact of reimbursement on margin</li></ul><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:07:163Drug Pricing Explained: The Numbers That Drive Marginfull<![CDATA[🚨 April 2026 CMS HCPCS Quarterly Update 🚨]]>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 crucial for protecting margins

Links

HCPCS Quarterly Update

Quarterly Addenda Updates

ASP Pricing Files

Disclaimer

This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>0ea6f0fb-2971-439c-8b18-ae8691dfba90Mon, 13 Apr 2026 21:52:09 GMT<p>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.</p><p></p><p><b>Takeaways</b></p><ul><li>CMS Quarterly Updates are a reimbursement roadmap</li><li>Understanding the CMS files is crucial for protecting margins</li></ul><p></p><p><b>Links</b></p><p><a rel="noopener noreferrer nofollow" href="https://www.cms.gov/medicare/coding-billing/healthcare-common-procedure-system/quarterly-update" target="_blank">HCPCS Quarterly Update</a></p><p><a rel="noopener noreferrer nofollow" href="https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps/quarterly-addenda-updates" target="_blank">Quarterly Addenda Updates</a></p><p><a rel="noopener noreferrer nofollow" href="https://www.cms.gov/medicare/payment/part-b-drugs/asp-pricing-files" target="_blank">ASP Pricing Files</a></p><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:12:292🚨 April 2026 CMS HCPCS Quarterly Update 🚨full<![CDATA[What is the Pharmacy Revenue Cycle and Why it Matters Now]]>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 cycle

Links

ASHP Pharmacy Revenue Cycle Management Certificate

Disclaimer

This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.

Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.

All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.

While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.

By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.

]]>508a8cf2-caca-4442-aa33-dc76fb43e4deMon, 13 Apr 2026 21:49:01 GMT<p>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.</p><p></p><p><b>Takeaways</b></p><ul><li>Pharmacy revenue cycle as a strategic driver</li><li>Aligning pharmacy, revenue cycle, and finance</li><li>Operational and financial complexity in pharmacy</li><li>Creating an integrated system for pharmacy revenue cycle</li></ul><p></p><p><b>Links</b></p><p><a rel="noopener noreferrer nofollow" href="https://elearning.ashp.org/products/12885/pharmacy-revenue-cycle-management-certificate" target="_blank">ASHP Pharmacy Revenue Cycle Management Certificate</a></p><p></p><p><b>Disclaimer</b></p><p>This podcast is for informational and educational purposes only. The content shared reflects my personal views and experiences and does not represent the views of my employer, any affiliated organizations, or any institutions I am associated with.</p><p></p><p>Nothing discussed on this podcast should be interpreted as legal, financial, medical, or reimbursement advice. Listeners should consult their own legal counsel, compliance teams, or qualified professionals before making any decisions based on this content.</p><p></p><p>All examples and scenarios discussed are generalized or de-identified to protect confidentiality and comply with applicable privacy laws.</p><p></p><p>While I strive to provide accurate and up-to-date information, healthcare regulations, payer policies, and reimbursement models are constantly evolving, and I make no guarantees regarding completeness or accuracy.</p><p></p><p>By listening to this podcast, you acknowledge and agree that any reliance on the information provided is at your own risk.</p>no00:14:221What is the Pharmacy Revenue Cycle and Why it Matters Nowfull