Foresight helps office-based MOUD and telemedicine teams verify coverage at intake and every visit, track pharmacy-benefit PAs, protect high-risk refills, route rendering providers by state, and distinguish self-pay, no-charge, and credentialing back-bill cases.
Addiction revenue work is clinically time-sensitive. A stale Medicaid plan, wrong MCO, pharmacy-benefit PA delay, film-versus-tablet formulary denial, missing counseling evidence, or wrong state rendering provider can interrupt a buprenorphine refill and create both revenue and care-continuity risk.
Run eligibility before intake, before each recurring visit, and before refill-sensitive milestones for patients likely to churn coverage.
Track medication authorization status from pharmacy rejection through approval, appeal, peer-to-peer, medication change, or expiry.
Route appointments to a provider credentialed for the patient state and payer before the visit rather than correcting after charge capture.
Separate pharmacy-benefit PA work from medical-claim denial work, especially when a Medicaid plan treats the oral product, injectable product, and administration line differently.
Classify uninsured, Medicaid-pending, self-pay, and credentialing-hold patients with explicit billing rules and patient-facing consent.
Foresight checks whether required evidence is present, whether records contradict each other, and whether the available facts look approvable under payer criteria before submission.
Check Member ID, active Medicaid/MCO, pharmacy benefit, patient state, rendering provider state enrollment, DEA profile, PDMP, UDS, counseling or treatment-plan evidence, product form, quantity, NDC, PA expiry, and self-pay or no-charge acknowledgment.
Surface mismatches between eligibility and pharmacy rejection, film versus tablet documentation, Medicaid-pending versus cash-pay handling, office-based MOUD versus OTP bundle logic, or injectable inventory that does not support the billed medication line.
Apply state Medicaid and MCO rules for oral and injectable MOUD, high-dose continuation, product-form exceptions, counseling/monitoring requirements, medical-versus-pharmacy benefit routing, and refill-sensitive PA windows.
A useful audit scores concrete workflow gaps: missing evidence, contradictory records, payer criteria risk, and follow-through after submission.
Whether the claim, PA, or appeal has the basic identifiers and clinical anchors needed before work leaves the queue.
Where the EHR, notes, questionnaire, inventory, pharmacy response, and billing record point to different answers.
Whether the available evidence appears to satisfy payer criteria before the submission creates AR or appeal work.
Whether approvals, denials, paper EOBs, portal messages, corrected claims, and deposits resolve cleanly after submission.