Revenue Rx

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.TakeawaysBagging crisis impacts patient care, operational efficiency, and financial sustainabilityDifferent bagging models have unique challenges and implicationsChapters00:00 Introduction to the Bagging Crisis00:34 Patient Impact02:08 Impacted Therapies03:46 Buy & Bill04:35 Brown Bagging05:22 White Bagging06:01 Orange Bagging07:20 Clearbagging09:27 Gold Bagging12:07 DIsclaimerLinksVizient Survey on the Patient Care Impact and Additional Expense of White/brown BaggingASHP White-Bagging InfographicAsembia Specialty Pharmacy Drive-by ModelDisclaimerThis 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.

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.TakeawaysPrior authorizations are critical for determining reimbursementUnderstanding the different reimbursement processes for pharmacy and medical benefits is essentialChapters0:02 Introduction1:05 Why Prior Authorizations Matter2:16 Pharmacy vs. Medical Benefits3:53 Key Terms Defined6:08 Where Organizations Go Wrong8:57 High-Performing Organizations & AI11:13 DisclaimerLinks2024 AMA Prior Authorization Physician SurveyDisclaimerThis 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.

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.TakeawaysCharge 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.DisclaimerThis 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.

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.TakeawaysComplexity of drug pricingImpact of reimbursement on marginDisclaimerThis 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.

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.TakeawaysCMS Quarterly Updates are a reimbursement roadmapUnderstanding the CMS files is crucial for protecting marginsLinksHCPCS Quarterly UpdateQuarterly Addenda UpdatesASP Pricing FilesDisclaimerThis 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.

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.TakeawaysPharmacy revenue cycle as a strategic driverAligning pharmacy, revenue cycle, and financeOperational and financial complexity in pharmacyCreating an integrated system for pharmacy revenue cycleLinksASHP Pharmacy Revenue Cycle Management CertificateDisclaimerThis 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.