By Chris Fitzmaurice, PharmD, Vice President of Pharmacy Strategy and Informatics, ScriptPro
More reimbursement complexity means more revenue at risk
Most discussions about Medicare’s Maximum Fair Price (MFP) program focus on drug pricing. What receives less attention is what happens after the prescription is dispensed.
For pharmacies, an equally important question is emerging: Are you receiving every MFP payment owed?
As more drugs move under MFP rules, pharmacies are being asked to reconcile reimbursement through a process that is significantly more complex than what they’ve managed historically. The challenge isn’t simply getting paid. It’s confirming that every payment arrived, every amount is correct, and every outstanding balance gets resolved.
Why visibility matters more than ever
Under MFP, reimbursement no longer arrives through a single transaction.
Part of the claim is paid by the patient’s Part D plan, while a separate payment is made by the manufacturer of the drug. Before a claim is truly complete, both payments must be received, tracked, and reconciled.
That may sound manageable on a handful of claims. The challenge comes with scale.
In comments submitted to CMS this summer, the American Hospital Association noted that hospitals and their pharmacy partners are already encountering difficulties identifying eligible claims, reconciling payments, and resolving discrepancies.
The underlying issue isn’t unique to hospitals. It’s operational visibility.
This isn’t just a hospital problem
Independent pharmacies identified similar concerns before the program launched. While the financial impact will vary by organization, the common thread is straightforward: reimbursement now involves more moving pieces, more tracking, and more opportunities for something to fall through the cracks.
I’ve spoken with pharmacy leaders who are responding by increasing their focus on therapeutic substitution where clinically appropriate alternatives exist. That’s a reasonable strategy, but it only addresses future prescribing decisions.
It doesn’t eliminate the need to reconcile claims that have already been dispensed.
For every medication that remains under MFP, someone still needs to verify that reimbursement is complete and accurate. As additional drugs are added to the program, that workload will only increase.
An added layer of complexity for 340B entities
For many 340B covered entities, the challenge becomes even greater.
These organizations often purchase brand medications well below standard acquisition cost. That discount doesn’t protect them from MFP. It can actually make reimbursement discrepancies more financially significant.
The move toward rebate-based reimbursement also creates a financing challenge. Instead of receiving an upfront discount, organizations may need to purchase medications at full price and wait for reimbursement later, increasing the amount of cash tied up in high-cost drugs.
Beginning January 1, 2027, some organizations may face an additional layer of complexity. Under HRSA’s revised 340B Rebate Model Pilot Program, covered entities may need to track three separate payment events tied to a single prescription instead of two.
Whether an organization is tracking two payments or three, the objective remains the same: know what was owed, what was received, and what still requires follow-up.
Three habits that improve reimbursement visibility
Organizations adapting most successfully tend to share several practices:
- Match payments to dispensed prescriptions as close to real time as possible.
- Review reimbursement at the claim level rather than relying solely on aggregate reporting.
- Establish ownership and follow-up processes for aging claims before they become larger collection issues.
How Financial Advantage helps
Financial Advantage was built to help pharmacy and finance teams answer a simple question: Are you receiving every MFP payment owed?
By reconciling revenue at the claim level, teams can identify discrepancies, prioritize unresolved claims, and improve visibility into third-party reimbursement activity, including MFP and 340B-related claims.
As reimbursement models continue to evolve, the pharmacies best positioned for success won’t necessarily be the ones facing the fewest challenges. They’ll be the ones that can identify issues quickly and take action before those issues become lost revenue.