The demands on claims editing systems are only getting tougher as healthcare needs become more complex. With care delivery evolving, spending rising, and policies and codes constantly shifting, payers are under growing pressure to keep plan spending in check. As regulations get more complex, the risk of errors and drawn-out payment processes only increases. The good news? Modern claims editing tools are helping to cut through the noise. Whether it’s the first pass, second pass or data mining, modernized approaches are making it easier to prevent and catch mistakes, streamline operations, and stay ahead in a rapidly changing landscape. Here are three areas you shouldn’t pass up to improve your claims editing system.
Three Essentials for a Modern Claims Editing Strategy
1. Continuous Updates & Optimizations
Code, policy, guideline changes—oh my.
In 2024, the American Medical Association announced 349 editorial changes to the CPT codes, including updates for areas such as Respiratory Syncytial Virus (RSV) and COVID-19, as well as adjustments and consolidations to evaluation and management (E&M) codes. The Centers for Medicare & Medicaid Services followed with 395 changes to the ICD-10 codes. Similar trends are anticipated for 2025, continuing the ongoing shifts in medical coding that must be accounted for by claims editing systems. Staying on top of these changes is important for your plan as a home plan to members, but also providing the same meticulous attention to claims with hosted members. Keeping up with these updates often involves manual efforts or band-aid fixes, like disabling edits that might be affected. Health plans that don't stay current face a steep uphill administrative battle, or financial risks; such as overpayments, errors, provider abrasion or lawsuits related to underpayments.
Enter Generative AI (GenAI). Equipped with web scraping to find policy, guidelines, fee schedules and other information, GenAI can summarize documents and pull codes and rules out of policy and guidelines, keeping edits fueled with the latest regulations. This makes updates and optimizations much faster, more comprehensive and easier than a manual, mundane to-do list. Watch our recent video to learn more.
2. Edit Ideation, Testing & Validation
Measure twice, cut once.
We’ve discussed the changes in codes, policy or guidelines - however, optimizing your existing edits only takes you so far. Access to care can change or new trends can arise which can create new cracks in your plans’ payment integrity. Cracks can be sealed with new concepts - but new edits can have a ripple effect on your plan if not deployed thoughtfully.
Misfired or inaccurate edits can create a cascade of issues—think a flood of false positives or unnecessary provider abrasion and increased administrative work on the plan’s side - including lengthy appeals processes. That’s why having a dedicated testing environment is key. It helps catch these issues before they cause real-world headaches or other financial losses.
But pre-deployment checks aren’t enough on their own. By continuously analyzing utilization trends, digging into cost center data for high-spend areas that current edits don’t address, and incorporating automated policy analysis, health plans can zero in on where newly formed concepts could have the most impact. Data-driven ideation is essential for new content generation to capture the most value.
Sandbox environments make it easier to test out new ideas safely, letting teams run what-if scenarios and A/B tests—or even stage "concept bakeoffs"—to fine-tune edits. It’s all about ensuring the changes make sense and deliver results before they go live. These tests can be run in parallel to existing edits and concepts to understand the broader impact before moving to production.
2. Auditability & Workflow Management
Track, run & manage—explainability is crucial.
To get the most out of new and optimized concepts, it’s important to keep workflows smooth and have strong audit tracking in place. Effective management, ongoing maintenance and understanding the changes within these processes can make a big difference in how well your strategy performs, ensuring that everything runs seamlessly and stays on track. Version control can help teams track, run and manage separate versions of concepts for claims on either side of a policy or guideline change.
With constant change and evolution, explainability and transparency in these systems is crucial to map back to certain policy changes or tweaks influencing concept deployment and optimization. Collaboration is key across health plan teams to deliver the insights and information critical to influence across the plan, claims operations, clinical services, network management, reimbursement policy teams,
Today’s tools allow for comprehensive workflow tracking, and change control and improved transparency to promote and improve collaboration, alignment and value across the healthcare organization.
Giving Your Approach an Upgrade
As healthcare and claims processing get more complicated, payers face no shortage of challenges—from keeping policies current to adapting to an evolving care landscape. Modernized claims editing systems are helping to leverage these changes and complexities into additional opportunities for payment accuracy. With AI-driven updates, testing environments, and streamlined workflows, these tools go beyond capturing errors to truly enhancing operations and reducing provider abrasion. As the landscape shifts, and demand on editing systems continue to rise, the path forward is clear: staying agile, embracing new tech and approaches that don’t just keep up with change but get ahead of it.
To learn more about Shift's solutions for Payment Integrity, request a demo here.
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