Revenue Cycle Management encompasses all the administrative and clinical functions involved in capturing, managing, and collecting patient service revenue. It starts when a patient schedules an appointment and ends when all payments have been collected. The process includes patient registration, insurance verification, charge capture, claim submission, payment posting, and denial management.

A prior authorization is approval from a health insurance company required before certain medications, procedures, or services can be provided. Without this approval, the insurance may deny coverage, leaving the patient responsible for the full cost. Prior authorizations are designed to control costs and ensure medical necessity, but they often create administrative burdens and delays in patient care.

Manual RCM and PA processes are expensive, error-prone, and slow. Every denied claim costs an average of $48 to rework, 8% of revenue disappears into billing complexity, and clinicians waste 2 hours daily on administrative work that takes them away from patient care. Automation handles repetitive, rules-based tasks faster and more accurately than humans, allowing your staff to focus on complex cases that truly require human judgment and expertise. The result is faster payments, fewer denials, and more time for patient care.

Automation-first means the system is designed to handle as much work as possible without human intervention. Foresight processes claims and prior authorizations automatically when confidence is high, only surfacing items to your queue when they genuinely need human review. This is the opposite of traditional systems that require humans to process everything and use automation as an occasional helper.

Others vendors offer mostly workflow management (rather than automation), or rely heavily too heavily on AI for everything, which can be unpredictable and hard to audit. Foresight uses a hybrid approach: deterministic, rules-based processing for predictable fields like patient demographics, place of service codes, and time-based E/M coding, with AI only deployed where it's truly needed—like extracting ICD-10 and CPT codes from unstructured clinical notes. This means more predictable outcomes, full auditability, and transparency about how every decision was made. You'll always know whether a field came from a rule or from AI, with clear provenance labeling throughout.

Deterministic rules are predictable, traceable logic that always produces the same output for the same input. For example, if a patient had a 32-minute video visit, we can deterministically set the place of service to 10 (home) with Modifier 95 for telehealth. AI is only used when rules can't handle it—like extracting diagnosis codes from a clinician's free-text notes. This hybrid approach gives you the best of both worlds: reliability where possible, intelligence where necessary, with complete transparency about which method was used for every field.

Provenance tracking shows you exactly how each field in a claim or PA was populated—whether it came from a database field, a rule, or an AI extraction. This is critical for audits, compliance, and trust. If a payer questions a code or a claim is denied, you can trace back exactly where that information came from, what confidence score the AI assigned (if applicable), and make informed decisions about whether to appeal or correct it. Complete transparency builds confidence in automation.

Foresight achieves a 92.1% first-pass rate, meaning 92 out of 100 claims are accepted on first submission without requiring corrections. PA first-pass rate is similarly high. This matters because rejected claims cost time and money to rework, delay payment, and hurt cash flow. A high first-pass rate means your revenue arrives faster and your staff spends less time fixing errors. Our pre-submission scrubbing catches formatting and content errors before they ever reach the clearinghouse.

Our denial rate is 4.8%, significantly below the industry average of 10-15%. We achieve this through payer-specific playbooks, pre-submission validation rules, and continuous learning from past denials. Every denied claim is analyzed to understand the CARC/RARC denial reason codes, and we automatically apply fixes when possible before resubmission.

Approximately 85% of claims and prior authorizations are auto-handled without requiring human intervention. Only items with low confidence scores, unusual patterns, or specific payer requirements that can't be automatically resolved are surfaced to your queue for review. This means your staff can process 6-7 times more work than with manual workflows.

Our average time-to-submit is 0.8 days (less than 1 business day) from when encounter data is available to when the claim is submitted to the payer. This is achieved through automated extraction, rules-based validation, and pre-submission scrubbing that eliminates delays. Compare this to the industry average of 3-5 days for manual processing.

Foresight integrates with all major EHR/EMR systems. We also support custom-built EHR systems. Our integration uses industry-standard FHIR and HL7 protocols, meaning we can connect to virtually any system that exposes these APIs. During implementation, we map your specific EHR fields to our system so data flows seamlessly.

This is exactly where Foresight excels. While we prefer to extract data from structured database fields (faster, more reliable), we can also ingest unstructured clinical notes and use AI to extract diagnosis codes, procedure codes, and other relevant information. For example, if an ICD-10 code isn't stored in a structured field, we'll analyze the provider's assessment and plan notes to identify the appropriate diagnosis codes with confidence scores.

During onboarding, we configure payer-specific rule packs tailored to your contracts and requirements. These include required modifiers, bundling rules, timely filing windows, prior authorization requirements, and credentialing checks. As we process claims, the system continuously learns from denials and adjusts rules to improve performance with each payer. You can also manually configure custom rules for unique payer relationships.

Foresight transforms denials from dead ends into opportunities for recovery. When a claim is denied, we automatically analyze the CARC (Claim Adjustment Reason Code) and RARC (Remittance Advice Remark Code) to understand exactly why it was rejected, and similar rejection reasons for PAs. We then apply payer-specific denial playbooks—automated fixes tailored to each denial reason. For example, CARC 197 (missing authorization) triggers an automatic check of our ePA system to attach the authorization and resubmit. You see denial patterns by payer and provider, and the system continuously learns from past performance to prevent future denials.

Foresight pulls encounter and medication/procedure data from your EHR, automatically answers payer-required clinical questions using both structured data and AI extraction from notes, and submits the PA request through electronic APIs or we pre-fill information in submission portals. We track PA status through approval or denial and implement automatic retry policies when a PA is denied. If we can't complete a PA with high confidence, it's surfaced to your queue for human review before submission.

Yes. Foresight is designed with HIPAA compliance from the ground up. All PHI (Protected Health Information) is encrypted in transit using TLS 1.3+ and at rest using AES-256 encryption. We maintain comprehensive audit logs of every access to patient data, including who accessed it, when, what they did, and from what IP address. We provide Business Associate Agreements (BAAs) for all customers and maintain compliance with all HIPAA Security Rule requirements.