💳 Payors & Risk

3 / 515 min

💳Module 4 · Slide 12

Payor Risk — What Can Go Wrong?

Payor risk is real and it can hurt us financially. But knowing the risks also helps you spot the opportunities.

Key Risks & Opportunities

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Network Exclusion

A PBM won't let us in — we can't service the patient at all. Always verify network status first.

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White Bagging

Payor forces drug from their own specialty pharmacy, cutting us out of drug revenue. Often makes case unviable.

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Site-of-Care Mandates

Payors pushing patients OUT of hospitals = opportunity for us. This is a major growth driver.

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Benefit Shifts

Drug moves from medical to pharmacy benefit — reimbursement and network requirements change.

⭐ Turn Risk Into Opportunity

Site-of-care mandates — where payors push patients out of hospitals — are actually a big opportunity for us. When a physician's hospital outpatient infusion gets denied, we're the solution. Know the risks, but always look for where the opportunity is.