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 provider is licensed in Texas. The patient is at home in Texas. The visit is synchronous via video. These facts don't require AI to verify—they're deterministic. If patient location = Texas AND provider license state = Texas AND visit type = video, then apply POS 10 (patient's home) + Modifier 95 (synchronous telemedicine). This rule will fire correctly 100% of the time.
But that same visit also has a 32-minute consultation note with unstructured clinical documentation. Extracting "G20.A1 - Parkinson's disease without dyskinesia" from narrative text like "Patient presents with pill-rolling tremor at rest, bradykinesia noted during finger tapping, cogwheel rigidity in upper extremities" absolutely requires AI. No rule can map that clinical description to the correct ICD-10 code with sub-classification.
The insight that drives modern RCM automation: These aren't competing approaches. They're complementary capabilities that solve fundamentally different problems.
RCM Market LANDSCAPE
The RCM market is bifurcated between Legacy Incumbents (R1, Optum, Conifer, Ensemble) who sell scale/BPO stability, and AI Point Solutions (AKASA, Cohere, Fathom) who excel in one narrow area. Foresight occupies a strategic "Blue Ocean" position as the End-to-End Automation Layer: Unlike point solutions, Foresight covers the full loop (Eligibility → PA → Claims → Denials). Unlike incumbents, Foresight is built on modern, event-driven architecture rather than legacy BPO labor. This positions Foresight uniquely for the specialty telehealth mid-market—a $3-5B segment that enterprise players ignore and point solutions can't serve comprehensively.
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 clinic faced ballooning Accounts Receivable (AR), a lack of visibility into claim statuses, and a bottleneck in financial reconciliation.
By implementing Foresight, the clinic moved from a manual, spreadsheet-dependent workflow to a fully automated, event-driven RCM system. This transition streamlined claim submissions, automated payment posting, and eliminated the manual labor of matching bank deposits to insurance explanations of benefits (EOBs).
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 on a team of 50 coordinators spending 20–30 minutes per case manually typing data into payer portals.
We deployed an end-to-end automated Prior Authorization (PA) pipeline that reduced the dedicated team to just 6 coordinators while maintaining a 95% automation rate. The system slashed processing time to under 1 minute for most cases and enabled real-time status synchronization, transforming a multi-day manual slog into an instant background process.
Comparing Top RCM & Prior Authorization Solutions
Revenue Cycle Management (RCM) and prior authorizations (PA) are critical yet challenging areas for healthcare providers. From the perspective of a CFO, practice manager, or revenue cycle director, choosing the right solution can greatly impact financial health and efficiency. In this post, we compare our unified RCM + electronic prior auth platform against leading alternatives in the market. We’ll look at both broad end-to-end RCM systems and specialized PA/automation solutions, highlighting their strengths, limitations, and ideal use cases – and why our platform offers a compelling choice for many provider organizations.