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.

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.

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.

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.

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.

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.