Breaking Down Claims Errors

The Top Trends Costing You Time and Money

In the world of claims management, even the smallest errors can ripple into larger inefficiencies, wasted resources, and strained relationships with providers and members. For payers and TPAs, identifying and addressing these errors is critical to maintaining operational excellence. Let’s break down some of the most common claims error trends — and how they could be costing you valuable time and money.

1. Rejections and Returns: A Costly Cycle

Claims rejections and returns often stem from incorrect data entry, coding errors, or missing information. While these errors may seem minor, they can trigger a chain reaction of delays and rework that drains time and resources.

The Fix: Implementing proactive validation checks and automation tools can help catch errors before claims are submitted, reducing the likelihood of rejections and keeping the process on track.

2. Wrong Address, Wrong Outcome

A seemingly simple error like an incorrect provider or member address can lead to misrouted communications, delayed payments, and frustrated stakeholders. The administrative costs of correcting these errors add up quickly.

The Fix: Regularly updating address databases and incorporating address validation tools can ensure claims are routed correctly the first time.

3. Incorrect Member Attached: A Mismatch with Major Implications

Attaching the wrong member information to a claim can result in payment delays, compliance risks, and potential member dissatisfaction. This error is particularly challenging because it often goes unnoticed until it’s escalated by a provider or member.

The Fix: Cross-referencing member data during claims intake and using automated verification systems can minimize these mismatches and streamline the process.

4. Missing or Incomplete Information

Incomplete claims — whether due to missing documentation, omitted codes, or inaccurate data—are a leading cause of processing delays. They require follow-up communications with providers and additional administrative effort to resolve.

The Fix: Training teams to recognize common documentation gaps and leveraging process improvement tools to flag incomplete submissions can significantly reduce these occurrences.

5. Coding Errors: Small Mistakes, Big Costs

Incorrect coding, whether it’s due to human error or outdated codebooks, is a frequent culprit in claims errors. These mistakes not only delay processing but can also lead to compliance issues or financial losses.

The Fix: Ongoing training for claims processors and periodic audits of coding accuracy can help catch and correct errors before they escalate.

Partner with Clarity for Error-Free Claims Management

At Clarity, we specialize in helping payers and TPAs overcome the most common — and costly — claims error trends. Our tailored solutions combine expert consulting with advanced tools to ensure accuracy and efficiency across every step of the claims lifecycle. Let’s talk about how we can help you reduce errors and reclaim your time.