Turning Reconciliation Into an Engine for Revenue Growth

At the Total Pharmacy Solutions Summit Summer 2025 event, a third-generation pharmacist, Heidi Polek, RPh, EMBA, discussed the importance of revenue cycle management (RCM) for pharmacies navigating increasingly complex financial landscapes. RCM has become a critical component of pharmacy financial health in an increasingly complex health care landscape. As pharmacies face mounting challenges from changing reimbursement models, regulatory requirements, and rising costs, understanding and effectively managing revenue cycles has never been more important.

Polek highlights several significant challenges facing pharmacies, including the Medicare Prescription Payment Plan 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.

Understanding and effectively managing revenue cycles has never been more important. | image credit: Hospital man / stock.adobe.com

“I think the hardest parts of our job to accept are the business decisions that we now have to make,” Polik said. “When I first got into pharmacy, you could just feel that focus on patients, and I know it’s still there, but so many of our decisions today have a business aspect to them. So...making sure that you are driving as much revenue through your pharmacy as possible to keep that pharmacy financially healthy is so important today—more important than ever.”

READ MORE: Strategies for Expanding Revenue Streams in Independent Pharmacy Today and in the Future

Read on for key takeaways:

• RCM is essentially a sophisticated method of tracking expected revenue from billed claims and matching them to actual payments. It’s comparable to balancing a personal checkbook but on a much larger and more complex scale. The process begins with maintaining accurate patient insurance data and implementing preadjudication edits in dispensing software to catch potential billing issues before claim submission. These proactive steps can significantly reduce transaction fees and streamline the billing process.
• Polek emphasized the critical importance of up-to-date technology in managing revenue cycles. Outdated systems not only pose security risks like potential ransomware threats but also complicate revenue tracking. Pharmacies must invest in modern technology and develop robust policies and procedures to ensure efficient claims processing, audit compliance, and minimal revenue leakage.
• She also detailed upcoming regulatory changes that will significantly impact pharmacy revenue management. Starting in 2026, the MFP program will introduce a new layer of complexity by requiring pharmaceutical companies to negotiate Medicare drug prices. This will necessitate pharmacies working with transaction facilitators and potentially experiencing payment delays of 30 to 120 days from traditional reimbursement timelines.
• Partnering with a professional RCM company can provide substantial benefits. Outcomes demonstrated recovering $3 million for clients in 2024 and were on track to exceed that in 2025. Professional RCM services can help pharmacies identify billing errors, improve cash flow, and allow pharmacy owners to reallocate resources toward patient care and business expansion.
• When choosing an RCM partner, pharmacies should conduct thorough due diligence. Key considerations include the company’s health care and pharmacy experience, types of claims reconciled, client satisfaction ratings, integration capabilities with existing pharmacy management systems, reporting features, and cost structure. Polek recommended asking detailed questions about transition processes, account management, and the company’s ability to chase down every potential revenue opportunity.
• Polek also highlighted that managing RCM internally can consume approximately 20 hours weekly, which is equivalent to approximately $5200 monthly in labor costs. Professional RCM services can often provide these services more efficiently and cost-effectively, allowing pharmacy staff to focus on patient care and core business operations.
• Pharmacies must be proactive in managing their revenue cycles. With increasing regulatory complexity, changing reimbursement models, and razor-thin margins, understanding and optimizing RCM is no longer optional but essential for survival and growth. By embracing professional RCM strategies, staying informed about regulatory changes, and continuously refining operational processes, pharmacies can navigate the challenging financial landscape and maintain a sustainable, patient-focused business model.

To read these stories and more, download the PDF of the Total Pharmacy August issue here.