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Insurance Department outlines provider audit problems, plans rules and investigations; committee will hold bill for interim study
Summary
The insurance commissioner described audits, prepayment review and ‘‘clawbacks’’ that sometimes leave small providers with unexpected account debits; department will issue a revised bulletin, file rule changes (INS 1003) and conduct targeted investigations before the committee acts.
DJ Betancourt, commissioner of the Insurance Department, briefed the Commerce and Consumer Affairs committee on complaints about carrier audits, prepayment review and post‑payment ‘‘clawbacks’’ of previously paid claims.
Betancourt told the committee that audits commonly follow automated red‑flag triggers when a carrier detects code‑use anomalies or billing pattern changes. The process often includes prepayment review to check future claims and occasionally a retroactive recovery (clawback) of prior payments. The commissioner said the department…
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