Introduction
As 2025 draws to a close, healthcare practices are facing an all-too-familiar challenge: the year-end scramble to reconcile outstanding claims. Between tighter payer scrutiny, shrinking reimbursements, and the looming risk of audits, the last quarter of the year often determines whether a practice starts the new year on solid financial footing—or carries over costly inefficiencies.
Outstanding claims, if left unresolved, can drain revenue, disrupt cash flow, and raise red flags with payers. For many practices, year-end is not just about closing the books—it’s about ensuring that every dollar owed is captured, documented, and compliant before entering 2026.
In this guide, we’ll break down exactly what outstanding claims are, why resolving them before year-end is essential, and five proven best practices for closing them out efficiently. We’ll also share how building a year-end resolution plan and leveraging MSO support can reduce revenue leakage and strengthen long-term revenue cycle management (RCM).
What Are Outstanding Claims in RCM?
In revenue cycle management, outstanding claims refer to bills for services already provided that remain unpaid, denied, or stuck in review. These typically fall into three categories:
- Unpaid claims: Submitted but awaiting payer adjudication.
- Denied claims: Rejected for errors, missing documentation, or non-coverage.
- Pending/unbilled encounters: Services rendered but never coded, billed, or submitted.
Outstanding claims accumulate for reasons such as payer delays, coding inaccuracies, incomplete patient demographics, or simple lack of follow-up. Each unresolved claim represents revenue at risk, and the longer it sits in accounts receivable (A/R), the harder it becomes to recover.
Within this spectrum, some claims may simply be stalled in payer review, while others require resubmission or appeals. Unbilled encounters represent an even more direct loss, as they reflect services that were never monetized in the first place.
Why Managing Outstanding Claims Before Year-End Matters
Unresolved claims are not just accounting line items—they directly impact financial health, compliance posture, and operational efficiency.
Financial impact: Carrying unresolved claims into the next year distorts cash flow, delays revenue recognition, and increases the likelihood of write-offs.
Compliance risks: Unresolved denials or improperly handled appeals can trigger payer scrutiny and increase audit exposure.
Operational strain: Staff are forced to juggle new claims with leftover backlogs, creating inefficiencies and missed opportunities for revenue capture.
Practices that actively resolve claims in Q4 gain a strategic advantage. For example, a multispecialty clinic that cleared 75% of its aged claims in Q4 reported a 12% improvement in year-end revenue, as well as stronger payer relationships going into contract renegotiations. In contrast, practices that delay often face higher denial rates in Q1, weaker cash flow, and strained staff morale.
5 Best Practices for Handling Outstanding Claims at Year-End
1. Conduct a Comprehensive Claims Audit
Start by categorizing outstanding claims by age (30, 60, 90+ days), dollar value, and payer type. This provides a clear picture of where revenue is tied up.
During the audit, look for:
- Denial trends by payer.
- High-dollar claims stuck in review.
- Common coding or demographic errors.
By identifying systemic bottlenecks, you can prioritize fixes that not only resolve current claims but also prevent future ones.
2. Prioritize High-Value and Aged Claims
Not all claims are worth the same effort. Claims over 60 or 90 days old are at the highest risk of non-payment, especially as timely filing limits approach. Similarly, high-dollar claims can significantly impact cash flow if left unresolved.
Use denial reason codes to assess the recovery potential. Some denials, like missing modifiers or demographic mismatches, can be quickly corrected. Others, such as non-covered services, may not be worth pursuing.
3. Strengthen Payer Communication and Follow-Up
Consistent, documented follow-up is the key to breaking payer bottlenecks. Best practices include:
- Using electronic payer portals and clearinghouses for real-time claim status updates.
- Escalating stuck claims when standard timelines lapse.
- Documenting every call, email, or portal interaction for compliance and audit readiness.
Persistence matters. Many claims are only paid after multiple follow-ups, and documented communication can support appeals or disputes if payers resist.
4. Improve Internal Workflows and Documentation
Outstanding claims often trace back to internal inefficiencies. Strengthening workflows reduces backlogs at year-end. Steps include:
- Assigning clear accountability for claim follow-up.
- Standardizing protocols for documenting payer interactions.
- Training staff on accurate coding and demographic capture.
Practices with clean data and strong front-end processes see fewer denials and faster resolutions, reducing year-end stress.
5. Leverage Technology and MSO Support
Automation and outsourcing amplify year-end efficiency. Tools such as analytics dashboards, denial management software, and claim scrubbing tools allow staff to quickly identify and resolve issues.
MSO partners like QMACS MSO provide:
- Year-end claim scrubs to catch errors before resubmission.
- Dedicated denial management teams to reduce A/R days.
- Analytics to identify payer trends and systemic bottlenecks.
- Scalable support for practices overwhelmed by claim backlogs.
With expert support, practices can resolve more claims faster—and enter 2026 with a clean slate.
How to Build a Year-End Claims Resolution Plan
A structured plan ensures claims don’t slip through the cracks. Best practices include:
- Start in Q4: Waiting until January reduces recovery opportunities.
- Assign ownership: Designate staff or teams responsible for aged claims, payer follow-ups, and documentation.
- Use reporting tools: Monitor A/R aging buckets, denial rates, and recovery percentages weekly.
- Ask critical questions:
- How many claims remain unresolved?
- What is the recovery potential of each claim category?
- Which payers are consistently problematic?
- How many claims remain unresolved?
By creating a timeline and assigning roles, practices can systematically reduce outstanding claims before year-end deadlines.
Common Mistakes Practices Make With Outstanding Claims
Even experienced practices make errors that undermine year-end revenue recovery. Common pitfalls include:
- Waiting until January to resolve Q4 claims, missing payer deadlines.
- Chasing low-dollar claims that cost more in staff time than they recover.
- Poor documentation of payer interactions, weakening appeals and audits.
- Lack of ownership, where no one is clearly responsible for claim resolution.
Avoiding these mistakes ensures resources are directed where they yield the highest ROI.
FAQs About Handling Outstanding Claims
How long do practices have to refile denied claims?
It depends on payer rules, but timely filing limits often range from 90 to 180 days.
What’s the average resolution time for outstanding claims?
Resolution can take anywhere from 15 days to several months, depending on payer response times and claim complexity.
Can smaller practices realistically manage year-end claims without outsourcing?
Yes, but outsourcing provides efficiency and expertise that smaller teams often lack, especially during year-end backlogs.
What role does compliance play in claim follow-up?
Compliance ensures payer interactions, appeals, and resubmissions are well-documented—protecting the practice during audits and disputes.
Final Thoughts
Closing out the year with clean claims isn’t just a best practice—it’s a financial and compliance necessity. Outstanding claims represent lost revenue, increased audit risk, and operational inefficiency. By auditing claims, prioritizing high-value accounts, improving workflows, and leveraging expert support, practices can end 2025 stronger and enter 2026 with confidence.
Don’t let unpaid claims roll over into the new year. Begin your year-end claims review today. Contact QMACS MSO to schedule a year-end claims resolution consultation, download our year-end checklist, or explore full-service RCM support tailored to your practice.