Struggling with unresolved claims edits and growing billing backlogs? In this post, we explore how one hospital cleared a mounting queue of claims edits—and why addressing these issues early can protect your revenue cycle. You’ll learn common challenges behind edit delays, strategies for sustainable resolution, and how to balance automation with expert oversight.
Case Study
A midsized hospital in the Southeast was facing an all-too-common issue: a growing backlog of unresolved claims edits. Their billing/coding teams were stretched thin, juggling coding clarification, edit work queues, and mounting denials. Claims were sitting in worklists for days—sometimes weeks—waiting for resolution. Revenue was delayed, and leadership struggled to pinpoint why the process kept stalling.
After bringing in outside help to work through the edits, the hospital cleared its backlog in under four weeks. But more importantly, they gained visibility into the root causes—and a workflow to keep things from piling up again. This wasn’t just a clean-up; it was a reset.
This scenario isn’t unique. Claims edits are one of the most persistent—and underestimated—obstacles in revenue cycle management. |
Claims edits are meant to protect revenue by flagging potential issues. But when not managed effectively, they do the opposite—stalling cash flow, increasing rework, and frustrating your staff.
From front-end billing edits that stop claims before submission to post-bill denials that demand deeper analysis, edits can easily become a moving target without a structured approach to triage and resolution.
Even high-performing coding and billing teams run into problems like:
What starts as a technical delay can quickly lead to bigger financial consequences.
Handling a backlog is one thing—keeping it from returning is another. The organizations that manage edits most effectively tend to share a few strategies:
Establish a regular rhythm for reviewing and addressing open edits, rather than reacting once issues grow.
Everyone on your team should know who owns what. This reduces delays and ensures accountability.
Technology can speed up simple edit resolution, but nuanced cases—especially those involving coding or documentation—still require human judgment.
Recurring edits offer a chance to train upstream—whether it’s documentation coaching or refining billing system rules.
Let’s be honest: most internal teams don’t have the bandwidth to manage edit resolution and keep day-to-day operations running. That’s why many hospitals and health systems work with outside partners—temporarily or long term—to keep claims edits from slowing everything down.
Health Information Associates supports organizations in resolving billing edits and denials, triaging worklists, and putting sustainable processes in place. Whether it's clearing a backlog or supporting ongoing maintenance, HIA helps revenue cycle teams stay ahead of the hold-up.
For more than 30 years, HIA has been the leading provider of compliance audits, coding support services and clinical documentation audit services for hospitals, ambulatory surgery centers, physician groups and other healthcare entities. HIA offers PRN support as well as total outsource support.
The information contained in this coding advice is valid at the time of posting. Viewers are encouraged to research subsequent official guidance in the areas associated with the topic as they can change rapidly.