Turning Reconciliation into a Revenue Growth Engine
Heidi Polek, RPh, EMBA, discusses how pharmacies must adopt strategic approaches to maintain financial health and continue providing patient care.
In a Total Pharmacy Solutions Summit featuring Heidi Polek, RPh, EMBA, vice president of product management at Outcomes, she delves into the critical importance of revenue cycle management (RCM) for pharmacies navigating increasingly complex financial landscapes. With rising drug costs, evolving health care regulations, and challenging reimbursement models, pharmacies must adopt strategic approaches to maintain financial health and continue providing patient care.
Polek highlights several significant challenges facing pharmacies, including the Medicare Prescription Payment Plan (M3P) and the upcoming Inflation Reduction Act's Manufacturer Fair Pricing (MFP) program. These initiatives will dramatically impact pharmacy reimbursements, potentially reducing payments for high-cost medications and introducing new administrative complexities. For instance, the MFP is expected to affect approximately 10 drugs in 2026, with the list expanding annually, potentially creating a $22,000 monthly financial impact for average retail pharmacies.
RCM emerges as a crucial solution for pharmacies to streamline billing processes, identify and recover missing revenue, and maintain operational efficiency. Polek recommends pharmacies carefully select RCM partners who offer comprehensive services, quick claim reconciliation, and robust reporting capabilities. Successful RCM implementation can help pharmacies recover significant funds, with Outcomes reporting nearly $3 million recovered for clients in 2024 and 2025. Key best practices include maintaining up-to-date insurance information, implementing pre-adjudication edits in dispensing software, and working closely with RCM experts who understand the intricate pharmacy reimbursement landscape. The ultimate goal is to allow pharmacists to focus on patient care while financial professionals manage the complex revenue recovery process.
Polek concludes that in today's challenging pharmacy environment, every penny counts, and pharmacies should seriously consider professional RCM support to navigate increasingly complex financial regulations and reimbursement models.
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