Case studies.
Prior authorization workflow for specialty clinics: how ePA actually works
ePA runs on two benefit rails, and the wrong one looks like a clinical denial. The eight-step prior authorization workflow for specialty clinics, where it breaks, and what to measure.
Insurance discovery for self-pay patients: an operator playbook for specialty clinics
Some of your self-pay patients already have coverage you never captured. How to run insurance discovery without creating denials or compliance problems: trigger timing, confidence thresholds, 42 CFR Part 2 suppression, and cost controls.
CO-50 denials at specialty clinics: the fix is the LCD, not more documentation
A Medicare CO-50 almost always means the billed diagnosis was not on the covered list in your MAC's LCD. You cannot document your way onto a coverage list. How to catch the mismatch at coding time, not on appeal.
Spravato prior authorization denials by payer: a 2026 playbook for specialty clinics
Where Spravato denials cluster, what treatment-resistant depression means at UnitedHealthcare, Cigna, Aetna, and Medicare as of mid-2026, the medical-versus-pharmacy fork, and the REMS documentation that fails an audit weeks later.
Coordination of benefits denials: fixing CO-22 before you submit
CO-22 is a sequencing error, not a claim error. Where coordination-of-benefits denials come from at specialty clinics, how Medicare Secondary Payer rules decide the order, and how to catch an ambiguous record before the claim is built.
Auditing AI prior authorization: a provider-side verification framework for specialty clinics
If your team already drafts prior authorizations with AI, the question is whether you can defend each one. A four-layer framework: citation grounding, payer-policy grounding, code cross-validation, and resubmission lineage.
What to scrub before you submit a Medicare claim at a specialty clinic
The cheapest place to work a Medicare denial is before submission. The four-layer pre-submission scrub: NCCI edits, PECOS enrollment, OIG and SAM exclusion screening, and place-of-service, taxonomy, and NPI consistency.
Why eligibility checks fail at specialty clinics in 2026, and how to catch each failure early
Most eligibility failures break on the provider side, not the patient's. Five failure modes, how to detect each before it cascades into a week of denials, and what a clean detection layer should cover.
Proof of timely filing: why a 999 won't save you and the 277CA will
A timely filing denial is the one you cannot argue on clinical merit. Most clinics lose the appeal because they submit a 999 or a screenshot instead of the 277CA. The acknowledgment chain that actually proves filing.
Why Your ERA and Bank Deposit Don't Match — and What Specialty Clinics Should Do About It
Your ERA shows $12,400 paid on Tuesday. Your bank statement shows $11,847 landing Thursday. Here's why that gap exists at specialty practices — and how to build a reconciliation workflow that catches it.
PLB Segments in 835 ERA Files: Why Auto-Match Plateaus at 80% in Specialty Clinics (and How to Fix It)
Why PLB adjustments break ERA auto-posting at specialty clinics. A field guide to FB, WO, L6, and 72 reason codes, recoupment timing, and the BPR balancing equation that closes auto-match gaps.
CMS Prior Authorization Transparency Is Live. Here's How Specialty Clinics Should Use the New Data
CMS-required prior authorization reports are now starting to appear, but the data is easy to misuse. Here's how specialty clinics should interpret the new metrics and turn them into payer-specific workflows.
Why ERA/835 Reconciliation Breaks at Specialty Clinics
Specialty clinics hit remittance failures generic PM workflows don't handle well. Here's where ERA/835 reconciliation breaks, from enrollment and routing to line-level matching and EFT reassociation.
Cigna TMS Prior Authorization Removal in 2026: What Billing Teams Need to Change Now
Cigna/Evernorth removed TMS prior authorization for contracted providers under Evernorth and Cigna Healthcare plans on March 6, 2026. Here’s what changed, what didn’t, and how billing teams should respond.
GLP-1 Prior Authorization: What Clinic Teams Need in 2026
A practical 2026 guide to GLP-1 prior authorization requirements by payer and PBM. Covers Wegovy, Zepbound, and Mounjaro workflows, recurring payer questions, denial patterns, turnaround times, and a clinic-ready submission checklist.
how Foresight Automates rcm: What Actually Works
Every week, we hear the same question from telehealth providers: "Should we use rules-based automation or AI for our revenue cycle?" It's the wrong question. Here's why: A Parkinson's disease telehealth visit generates a predictable pattern. The prov…
The 2025 RCM competitive landscape: Foresight vs. incumbents, AI-native startups, and niche players
A $172B RCM market split between legacy BPO incumbents and narrow AI point solutions — and where Foresight fits as the end-to-end automation layer for specialty telehealth.
Case Study: Automating RCM for a Specialized Infectious Disease Clinic
A specialized infectious disease clinic, managing a high-touch patient population of hundreds of patients was struggling with a disjointed Revenue Cycle Management (RCM) process. Relying on third-party contractors and antiquated manual workflows, the c…
Automating High-Volume Pharma Prior Authorization
Our client, a leading digital weight-loss clinic, faced a critical operational bottleneck: their rapid growth was outpacing their ability to process medication approvals. With 100,000+ GLP-1 prescriptions annually (e.g., Wegovy, Ozempic), they relied o…
Comparing Top RCM & Prior Authorization Solutions
Article comparing top and specialist medical RCM and prior auth vendors in the US
