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.

Revenue Rx is a business podcast hosted by Unknown Host, with 26 episodes on record and a Required Pod Score of 80.

Unknown Host hosts Revenue Rx, a business show with 26 episodes published.

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  Episode #27

  CMS Reimbursement Calendar: A Month-by-Month Guide

  Sep 28, 202610 min

  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 issues appear. Takeaways January, April, July, and October are key quarterly reimbursement checkpoints. April typically begins IPPS proposed rule season. July is a major month for OPPS and Physician Fee Schedule proposals. October 1 brings new IPPS policies and another quarterly update. November is typically outpatient final rule season. Chapters 00:00 CMS Reimbursement Calendar 00:48 January 01:48 February 02:08 March 02:31 April 03:27 May 03:43 June 04:01 July 05:07 August 05:52 September 06:29 October 06:57 November 07:31 December 08:30 Year at a Glance 09:32 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.

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  Episode #26

  Denied to Paid: Building Pharmacy Appeals that Work

  Sep 21, 202612 min

  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 why the denial code should drive the strategy, how to match documentation to the payer’s specific reason for denial, and what belongs in a strong appeal packet. We also walk through a medical necessity appeal example, including how payer coverage policies, clinical documentation, diagnosis information, and supporting evidence can turn a generic appeal into a defensible case. The goal isn’t to build the thickest appeal packet. It’s to identify the root cause, choose the right pathway, submit evidence that answers the payer’s question, and do it before the deadline. Takeaways Determine whether the denial needs a corrected claim, reconsideration, or formal appeal before escalating. Start with the claim adjustment reason code and investigate the workflow failure behind it. Match supporting documentation directly to the payer’s stated denial reason. Medical necessity appeals should demonstrate how the patient met coverage criteria or why an exception was clinically justified. Include complete claim and patient identifiers to prevent avoidable delays or returns. Track appeal deadlines at the individual claim level with a clear owner and next action. Explore manufacturer replacement programs when appropriate for qualifying high-cost medications. Measure appeal performance using overturn rate, dollars recovered, and the percentage of eligible denials appealed. Strong appeals are focused, evidence-based, timely, and built around the payer’s actual question. Chapters 00:02 Understanding Appeals in Pharmacy and Finance 00:54 Corrected Claim, Reconsideration, or Appeal? 02:17 Start With the Denial Code 04:27 Match the Evidence to the Denial 05:19 Building a Strong Appeal Packet 06:15 Building a Strong Medical Necessity Appeal 08:21 Appeal Deadlines Matter 09:27 Manufacturer Replacement Programs 10:13 Measuring Appeal Performance 11:04 What Makes an Appeal Get Paid 11:54 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.

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  Episode #25

  Closing the Loop: Stop Fixing the Same Denial Twice

  Sep 14, 202612 min

  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 upstream workflows and system builds, and turn payer-specific discoveries into institutional knowledge. We also discuss why corrective actions need clear ownership, deadlines, and measurable outcomes—and why successful revenue cycle programs should track not only recovered revenue, but also the revenue losses prevented when claims are paid correctly the first time. Takeaways Resolving a claim recovers revenue; correcting the underlying workflow protects future revenue. Categorizing root causes helps identify the team responsible for fixing the problem. Recurring authorization, documentation, coding, NDC, unit, modifier, and system-build issues should be addressed upstream. Successful appeals can reveal opportunities for prevention when the same denial repeatedly occurs. Education is most effective when teams understand exactly what needs to change and why it affects reimbursement. Every corrective action should have an owner, deadline, and defined method for measuring results. Measurement should focus on the specific denial, underpayment, documentation issue, or workflow that was changed. Prevented revenue loss may never appear on a recovery report, but it can represent some of the most valuable work performed by a mature revenue cycle program. A closed-loop revenue cycle becomes a learning system in which every denial, underpayment, and successful appeal improves future claims. Chapters 00:00 Closing the Loop in Pharmacy Revenue Cycle 01:21 Find the Root Cause 03:40 Fix the Upstream Workflow 04:05 Correct the System Build 05:51 Educate the Right Teams 07:26 Assign Owners and Deadlines 08:26 Measure the Fix 09:21 Recovered vs. Prevented Revenue 10:28 Build a Learning System 11:23 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.

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  Episode #24

  Rejections, Denials, and Underpayments: Diagnosing the Claim Before You Fix It

  Sep 7, 202611 min

  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 Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), and group codes work together to provide a clearer picture of claim outcomes. We also explore why clinical and administrative denials require completely different skill sets and workflows, using examples such as CARC 50 for medical necessity, CARC 197 for authorization requirements, and CARC 16 paired with RARCs that identify specific billing or documentation issues. Takeaways A rejection occurs before adjudication, while a denial occurs after the payer processes the claim and makes a payment determination. Rejected claims may not contain CARCs or RARCs because they never reached adjudication. CARCs explain why a payment was adjusted, while RARCs provide additional context about the adjustment. Group codes such as CO, PR, and OA help identify financial responsibility for adjusted amounts. A CARC does not automatically represent a denial; some adjustments are expected contractual or patient-responsibility outcomes. Clinical denials such as medical necessity or experimental and investigational determinations often require pharmacist, nurse, or prescriber involvement. Administrative denials such as missing prior authorization require workflow and operational fixes rather than clinical appeals. CARC 16 demonstrates why CARCs should be interpreted alongside RARCs to identify the actual root cause. Underpayments can create significant revenue leakage without generating a denial or work queue entry. Zero-pay and partial-pay claims must be evaluated against reason codes and contract terms before determining whether payment is correct. Rejections, administrative denials, clinical denials, and underpayments should not all be routed through the same workflow. Denial rate should be evaluated alongside rejection rates, underpayment variance, and zero-pay findings for a more complete view of revenue cycle performance. Chapters 00:00 Introduction 00:38 Rejections vs. Denials 02:16 Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), & Group Codes 03:36 Clinical Denials vs. Administrative Denials 07:22 Underpayments 08:44 Delegate Appropriately 10:43 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.

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  Episode #23

  Pharmacy Revenue Cycle KPIs: What to Measure and Why it Matters

  Aug 31, 202616 min

  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 deserves a place on a scorecard. A meaningful KPI should influence a decision, trigger an investigation, or lead to a workflow change. By connecting operational measures with financial outcomes, pharmacy revenue cycle teams can better protect patient access, reimbursement, cash, and margin. Takeaways A KPI should be connected to a priority and lead to action, not simply appear on a dashboard. Front-end KPIs such as pre-service authorization rate, authorization turnaround time, scheduled service clearance, and treatment delays can serve as leading indicators of future denials. Mid-cycle KPIs help identify problems with charge capture, reconciliation, billing units, modifiers, and clean claims. Back-end performance should be evaluated using both denial frequency and financial exposure, including denial dollars, preventable denials, recovery, aging, underpayments, and terminal write-offs. Negative-margin administrations, 340B capture, and cost to collect can provide additional insight into financial performance. Segmenting KPIs by payer, medication, drug class, location, and site of care can reveal problems that aggregated results may hide. Every KPI should have an owner responsible for investigating changes and coordinating corrective action. Operational KPIs show teams what needs to be fixed, while financial KPIs help explain to leadership why fixing it matters. Chapters 01:46 Front-end KPIs 04:01 Mid-cycle KPIs 06:24 Back-end KPIs 10:51 Financial KPIs 15:50 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.

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