Case Study: Automating RCM for a Specialized Infectious Disease Clinic
Executive Summary
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).
The Challenge: A Fragmented Revenue Cycle
Despite providing critical care, the clinic's back-office operations were hindering its financial health. The administrative team inherited a fractured tech stack where the EHR, the clearinghouse, and the document storage system operated in silos.
Key operational pain points included:
The "EOB Treasure Hunt": Staff spent hours logging into various payer portals to manually locate and download Explanation of Benefits (EOB) documents.
Manual Reconciliation Bottlenecks: The financial controller had to manually download bank statements and cross-reference them against claim spreadsheets to verify if payments had actually hit the bank account. This manual "stare and compare" process was the clinic's single largest administrative bottleneck.
Black Box Denials: Claims were frequently rejected due to coding errors or missing information. Because the billing contractors provided little feedback, the clinic lacked the data to correct root-cause issues, leading to an inflated denial rate.
Lack of Visibility: The leadership team had no real-time dashboard to track claim performance, relying instead on lagging monthly reports that offered no actionable insights.
The Solution: End-to-End Automation
Foresight deployed a unified RCM platform that integrated directly with the clinic’s existing EHR and financial infrastructure. By treating RCM as an automated pipeline rather than a series of manual tasks, the system addressed the friction points at every stage of the claim lifecycle.
1. Automated Payment Ingestion & Reconciliation
The most significant efficiency gain came from automating the cash posting process.
Programmatic Ingestion: Instead of staff manually downloading files, Foresight’s Payment Network Connector automatically pulls Electronic Remittance Advice (835 files) directly from the clearinghouse the moment they become available.
Auto-Reconciliation Logic: The system ingests digital bank statements from the clinic's document storage system. Using intelligent matching logic, Foresight automatically links specific bank deposits (EFTs) to their corresponding claim remittances.
The Result: The system now automatically flags which claims are "Paid & Deposited" and isolates only the "unreconciled" exceptions for human review, turning a weekly multi-hour chore into a rapid exception-handling task.
2. Intelligent Claim Scrubbing
To address the high rejection rate, Foresight introduced a "Submit & Listen" workflow.
Pre-Bill Edits: Before a claim reaches the clearinghouse, Foresight extracts data deterministically from the EHR. Where data is unstructured (e.g., clinician notes), the system uses AI to verify ICD-10 and CPT code validity against payer-specific rules.
Real-Time Validation: If a claim is missing critical information (such as a provider credential) the system flags it immediately in the Claims Workbench with a suggested fix, preventing the claim from being sent out to die.
3. Centralized Financial Command Center
The clinic replaced spreadsheets with the Foresight Dashboard, providing a single source of truth.
Unified Visibility: Staff can now view the lifecycle of every claim in real-time, from "Draft" to "Submitted" to "Paid."
Actionable Work Queues: Rather than hunting for work, staff are presented with prioritized queues (e.g., "Denial Review," "Unreconciled Payments"). This ensures that high-value claims requiring attention are addressed first.
The Impact
By removing the manual friction between systems, the clinic transformed its financial operations from a reactive struggle into a proactive, data-driven process.
90% Reduction in Reconciliation Time: Automated matching of ERAs to bank deposits eliminated the manual cross-referencing of PDFs and spreadsheets, saving the financial controller hours of work every week.
Accelerated Cash Flow: By catching coding errors pre-submission and automating the intake of payment files, the time from patient encounter to cash-in-bank was significantly reduced.
Elimination of "Black Box" Denials: With granular visibility into denial reasons (CARC/RARC codes) displayed directly in the dashboard, the clinic could identify and correct upstream coding behaviors, preventing future rejections.
Foresight enabled the clinic to scale its operations without adding headcount, allowing the team to focus less on paperwork and more on patient care.
