As hospitals and health systems evolve into risk-bearing organizations, many are launching their own health plans or taking on delegated risk through Medicare Advantage, ACOs, and MSOs. This shift creates new opportunities for financial sustainability, but also introduces new challenges.
One of the biggest? Rebates tied to drugs billed under the medical benefit.
The Overlooked Side of Rebate Management
For years, rebate strategies have focused almost exclusively on the pharmacy benefit. That made sense when most specialty spend flowed through pharmacy channels. But today, some of the highest-cost claims—including infused biologics and oncology therapies—are billed under the medical benefit.
Yet many provider-led health plans and MSOs lack the infrastructure to:
- Identify rebate-eligible medical claims
- Align documentation with manufacturer requirements
- Submit compliant data for rebate payout
The result? Untapped rebate revenue, distorted financial projections, and lost opportunities for savings.
Why Medical Rebate Management Matters
For provider organizations assuming financial risk, overlooking medical rebates isn’t just about lost income—it skews the entire financial picture. Without these dollars factored in, organizations risk:
- Underestimating opportunities for savings when forecasting budgets
- Overpaying in value-based arrangements due to incomplete net cost visibility
- Weakening negotiating leverage with payers and manufacturers
In a tight-margin environment, these gaps can directly impact financial performance.
Strategic Rebate Management: A Path Forward
This is where strategic rebate management becomes essential. At VativoRx, we partner with hospitals, MSOs, and provider-led health plans to ensure rebate programs are built for compliance, transparency, and long-term success.
Our approach to medical rebate management includes:
- Clean, compliant submissions that align with manufacturer requirements
- Cross-benefit visibility into both pharmacy and medical rebates
- Audit-ready documentation that safeguards revenue
- Actionable reporting that supports future financial planning
Rebates aren’t just a back-office function—they’re a critical lever for improving margins in risk-bearing models.
Real Talk from the Field
In dozens of conversations with provider-led organizations, our SVP of Sales, Jim Haidet, has heard a consistent theme: many plans are eager to innovate but often don’t realize just how much rebate value is being left on the table.
This is one of the most urgent, and fixable, opportunities for providers moving into financial risk.
The Bottom Line
Provider-led health plans are positioned to play a powerful role in reshaping care delivery and value-based care. But without the right medical rebate management strategy, they risk leaving critical dollars behind.
Are you leaving rebate dollars on the table?
Let’s talk about how VativoRx can help your organization capture every opportunity. Contact us here.
