The Path Forward: Navigating the Shift to Medical Billing
June 30, 2025
The role of pharmacies in the healthcare system is undergoing a dramatic shift—driven by legislative changes, patient care needs, medical billing demands, and rapid advances in technology. In a recent webinar hosted by XiFin and Drug Store News, titled “Navigating the Future of Pharmacy: The Next-Gen Medical Billing Roadmap,” a panel of industry experts shared insights into how pharmacies can adapt and thrive in this evolving environment.
At the heart of the discussion was a clear message: pharmacies must embrace change—not just react to it. Whether it’s tapping into new revenue streams through medical billing or leveraging AI and technology to streamline operations, the future of pharmacy is already taking shape.
A Legislative Landscape That’s Opening Doors
David Pope, Chief Pharmacy Officer at XiFin, opened the session by spotlighting key legislative trends. He pointed to a growing momentum behind expanding the pharmacist’s role, particularly through bills like H.R. 3164, which proposes expanding Medicare Part B coverage to include pharmacist-provided services such as testing and treatment.
Pope emphasized that this shift isn’t just theoretical—it’s already happening at the state and commercial levels. Medicaid programs and private insurers are increasingly recognizing the value of pharmacies as accessible clinical hubs, especially in underserved rural areas. However, Medicare has yet to fully embrace this, which presents a barrier to care for senior patients.
“We have bipartisan support. Over 170 organizations are behind this,” Pope said. “But it’s up to us to keep this moving forward—reach out to your representatives.”
Pharmacies Are Ready—but Face Real Barriers
XiFin recently conducted a 2025 Pharmacy Transformation Outlook Survey, which revealed that many pharmacies are eager to expand their clinical offerings. Services like chronic care management, medication therapy management, and even digital therapeutics and diagnostic testing are all areas of strong interest.
However, enthusiasm is tempered by real-world challenges. According to Sandra Greefkes, XiFin’s VP of Product and Partner Marketing, the top obstacle remains reimbursement. But staffing limitations, infrastructure issues, and timing constraints also emerged as major hurdles, complicating efforts to scale clinical services.
“These aren’t just financial problems—they’re operational,” Greefkes noted. “From understaffing to outdated workflows, pharmacies need support on multiple fronts.”
The Critical Role of AI and Technology in Modern Medical Billing
As pharmacies expand into clinical services, they are faced with the complexity of medical billing—and that’s where AI and technology step in. Pope and his fellow panelists stressed that relying on manual data entry and disconnected systems is no longer sustainable. Instead, embedded AI technology can automate insurance card capture, verify clinical and financial eligibility, estimate out-of-pocket costs, and even initiate clinical documentation before the patient arrives.
“We don’t want pharmacists hand-keying data or pushing paperwork,” Pope said. “Embedded AI should be doing the heavy lifting—freeing up pharmacists to focus on care.”
Ben Conroy, Director of RCM Operations, added that this is particularly important as pharmacies begin billing under the medical benefit for some services historically tied to the pharmacy benefit, such as HIV PrEP, DME, specialty medications, and even some chemotherapy infusion drugs. Under the medical benefit, these services demand a higher level of documentation, payor compliance, and claim processing sophistication—which embedded AI technology can help deliver.
A New Model for Patient Engagement
Improving the front-end experience for patients is just as important. Mike Fauver, XiFin’s VP of Enterprise Solutions, described a growing trend among hospitals and specialty pharmacies: building seamless digital front doors using advanced patient portals.
These technologies allow patients to schedule appointments, submit insurance details, and begin clinical documentation online—before they even set foot in the pharmacy. This not only improves the patient experience but also reduces friction in the billing and payment process.
“The patient portal should be an extension of your pharmacy,” Fauver said. “It’s about eliminating gaps and potential issues before they happen.”
From Fragmented Systems to Full Revenue Cycle Management
Behind the scenes, pharmacies and hospitals alike are recognizing that piecemeal solutions won’t cut it when it comes to the complex medical billing that many clinical services and specialty medications require. Fauver noted that leading organizations are shifting to comprehensive revenue cycle management (RCM) systems, capable of handling everything from verifying patient eligibility to claims reconciliation.
“Medical billing is too complex to manage in silos,” Fauver explained. “A full-path RCM system isn’t just nice to have—it’s essential for success.”
This shift is helping forward-thinking organizations streamline operations, boost reimbursement, and ultimately, deliver better patient care at scale.
A Roadmap to Success
The panel wrapped up by outlining six critical RCM capabilities that every pharmacy needs to have in place to take advantage of new revenue opportunities, increase efficiency, and maximize reimbursement.
- Patient Registration & Clinical Documentation – Standardized documentation protocols must be in place to support payor policy compliance and reduce denials.
- Payor Policy & Claim Submission – Consolidating multiple services into a single claim is now a payor requirement and is a must-have capability to optimize reimbursement.
- Denial & Appeals Management – As complexity increases, so does the volume of denials. A proactive, rules-based approach is needed to stay ahead.
- Patient Billing & Payment Management – With financial responsibility shifting to patients, they are demanding accurate cost estimates and a smooth payment experience.
- Payment Posting & Reconciliation – Pharmacies must gain real-time visibility into payor trends and patient responsibility to ensure cash flow and financial stability.
- Financial Reporting – Access to precise reporting tools help pharmacy leaders measure performance accurately and make informed decisions to ensure a financially healthy pharmacy.
Looking Ahead
The pharmacy of tomorrow won’t just fill prescriptions—it will offer high-value clinical services, bill under medical benefit, and engage patients through smart digital tools. But achieving this vision means embracing change today.
Legislation Is Catching Up. AI Is Ready. The Opportunity Is Now.
Pharmacies that take steps to modernize their billing infrastructure, advocate for policy change, and invest in scalable technology will be the ones that lead the industry forward.
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