Pharmacy Revenue Cycle Management: Priorities for 2026

Medication reimbursement presents one of the greatest opportunities for immediate financial improvement in today’s health systems. While many organizations continue to operate with limited visibility and fragmented processes, those that strengthen coordination across the pharmacy revenue cycle consistently unlock meaningful value. As drug costs rise and payer oversight increases, optimizing medication revenue has become one of the most impactful ways to enhance financial performance.

The Distinct Demands of Pharmacy Revenue Cycle Management

Pharmacy revenue is unlike any other area of hospital finance. Medications may be billed under the medical or pharmacy benefit, each with different systems, coding structures, and payer rules.

Infused and injectable drugs billed under the medical benefit require close coordination between pharmacy, billing, and clinical teams. Self-administered or specialty medications billed under pharmacy benefits—typically through pharmacy benefit managers (PBMs)—follow different workflows. When these processes remain siloed, denials and audit exposure increases.

As transparency mandates expand and drug prices fluctuate, hospitals must align these functions to ensure accuracy, accountability, and sustainable reimbursement.

From Discovery to Momentum: Building a Pharmacy Revenue Integrity (PRI) Team

The best place to start is with a Medication Revenue Tracer. This is a focused review of ten to fifteen high-cost medication claims that follow each charge through the entire reimbursement process from administration through to payment. The tracer identifies where authorization, documentation, coding, or billing gaps may exist and create revenue loss, and the insights gained form the foundation for action.

Establishing or strengthening a Pharmacy Revenue Integrity (PRI) team is the next step. A PRI team connects pharmacy, finance, revenue cycle, managed care, and payer contracting functions into a single accountable structure. Its mission is to ensure that medication billing and reimbursement is accurate, compliant, and optimized across all sites of care.

What Makes a PRI Successful?

A well-functioning PRI team brings together experts in pharmacy operations, charge capture, billing and coding, data analytics, and payer contracting. Together, they manage the full medication revenue process, from order entry and authorization to claim submission, payment reconciliation, and audit response. Their core functions include:

• Maintaining accurate and compliant charge description (CDM)
• Monitoring payer rules and policy updates to prevent denials.
• Aligning reimbursement processes with contract terms.
• Educating clinical and billing staff on documentation requirements.
• Analyzing trends to identify financial risk and recovery opportunities.

These teams prevent denials, strengthen charge accuracy, reconcile doses with charges, and ensure billing compliance. While artificial intelligence can automate simple edits, medication reimbursement is too variable and context-dependent to rely on automation alone.

Human subject-matter expertise is still needed to interpret payer rules, review documentation, and resolve complex issues. As a result, PRI teams often generate some of the highest returns on investment in a health system, recovering millions in missed revenue.

Price Transparency & The Pharmacy Revenue Cycle

Starting in 2026, new Centers for Medicare & Medicaid Services (CMS) transparency requirements will expand hospital reporting obligations inlcuding drug charges. Hospitals must publish payer-specific negotiated rates for all medications using standardized templates that include service descriptions, modifiers, and drug units of measure.

Drug charges are based on dynamic benchmarks such as Actual Acquisition Cost (AAC), Wholesale Acquisition Cost (WAC), Average Sales Price (ASP), or Average Wholesale Price (AWP), which may fluctuate by manufacturer and formulation. Hospitals also apply varying markups, minimum charges or dispensing fees depending on site of care, payer, or dose.

These updates increase both scrutiny and opportunity. Hospitals must ensure charge methodologies are clearly documented, consistent, and defensible in payer audits and public reporting. Clear communication with payers and patients is key, especially for those with coinsurance or copayments tied to a percentage of charges.

Six Pharmacy Revenue Cycle Priorities for 2026

1. Conduct a Medication Revenue Tracer and Gap Analysis

A Medication Revenue Tracer follows a set of high-cost drug claims through the entire reimbursement process to identify where revenue leakage occurs, from authorization through to final payment. The tracer also helps clarify who performs each step, often connecting team members who may have never collaborated before. This creates shared understanding, strengthens relationships across departments, and builds the foundation for coordinated improvements.

2. Launch or Strengthen a Pharmacy Revenue Integrity (PRI) Team

Developing a pharmacy revenue integrity team that is guided by strong pharmacy leadership and driven by collaboration across clinical, operational, and financial teams helps deliver some of the strongest financial returns in healthcare. By aligning these groups, medication reimbursement becomes more predictable, transparent, and sustainable, which supports an organization’s bottom line.

3. Optimize Biosimilar Selection & Formulary Governance

When multiple biosimilars are payer-approved, a biosimilar governance strategy minimizes denials and maximizes margins. Regularly evaluating charge structures and acquisition costs ensures each option supports both maximized reimbursement and compliance.

4. Refine Medication Charge Master Design

Medication charge master design must balance transparency and financial sustainability. While compliance rules push visibility, complex markup strategies create risk for undercharging. Modeling the impact of new charge structures across payers, IT systems, and billing workflows is exceptionally complex, but critical to maintaining fairness and fiscal responsibility.

5. Strengthen Payer Compliance

Even when claims are accurate, payers sometimes underpay or deny inappropriately. Tracking reimbursement variances and escalating systemic issues are essential to holding payers accountable and protecting an organization’s earned revenue.

6. Manage Site-of-Care Pressure and Retain Patients

Payers are increasingly steering patients toward lower-cost sites of care for infusion and specialty therapies, creating financial and operational risk for hospitals. To retain eligible patients and comply with site-of-care mandates, health systems must expand, coordinate, and centralize medication access support across inpatient, outpatient, and home infusion settings.

Building internal capacity and establishing consistent authorization workflows across these settings helps prevent patient leakage, maintain continuity of care, and preserve revenue. This integrated approach ensures patients receive therapies in the most appropriate location while safeguarding the organization’s financial stability.

Key Takeaways: Prepare for 2026 Pharmacy Revenue Demands

Successful pharmacy revenue integrity begins with visibility. A tracer helps identify where revenue and accountability are lost and helps clarify which teams touch each step in the process. Performance improves when pharmacy, finance, and revenue cycle work as an integrated team. Dedicated PRI resources then help to reduce denials, strengthen compliance, and deliver a high return on investment.

As transparency requirements grow, organizations must ensure their medication charges are consistent, defensible, and fair. With significant 2026 changes on the horizon, now is the time to elevate pharmacy revenue integrity as a strategic priority.

If your organization is ready to build a stronger pharmacy revenue integrity framework, Visante can help you get there. Our experts partner with health systems to enhance visibility, streamline workflows, and improve reimbursement accuracy.

Subject Matter Expert: Maxie Friemel & Tim Miller