Auditors presenting to the Group Insurance Commission on November 1 said preliminary reviews of the fiscal‑year‑2024 plan year revealed areas that require further investigation and, in some cases, operational correction.

"We are currently still in progress in reviewing those results with each of the plans and concluding on all findings," Marie Pollock, director of medical audits at CTI, said as she outlined the work. CTI and partner CXC analyzed both quantitative treatment limits (QTLs) — such as visit limits and cost sharing — and non‑quantitative treatment limitations (NQTLs), including prior authorization and network adequacy, under the Mental Health Parity and Addiction Equity Act (MHPAEA).

Pollock said all four carriers showed a recurring co‑payment classification issue for outpatient mental‑health and substance‑use disorder claims and identified visit‑limit questions for nutritional counseling, physical and occupational therapy, and smoking‑cessation services. On NQTLs, CTI flagged concurrent review, network reimbursement and adequacy, and coverage‑scope documentation as items for further GIC review.

On the claims-audit side, CTI reported that Health New England’s random‑sample audit of 200 claims showed no financial or procedural errors, while WellPoint’s 200‑claim random sample produced a 98.42% financial accuracy rate (a 1.58% error rate). The sample uncovered 11 errors that yielded $13,573 in overpayments and $279 in underpayments; CTI also found targeted‑sample errors including payments for plan exclusions and payments to sanctioned providers.

"For WellPoint, we identified systemic errors and recommended an off‑cycle audit in fiscal year 2025, with the carrier absorbing that audit cost," Pollock said. CTI also recommended carriers run impact reports and adjust affected claims where appropriate and suggested contract language to require carriers to compensate the GIC or members for errors identified through audits.

Commissioners pressed auditors for trend analysis and dollar extrapolations from sample error rates. Pollock said CTI can provide extrapolated estimates but treats them as best‑estimate scenarios and will supply the analysis to GIC staff for follow‑up. Commissioners also questioned whether fast median turnaround times (CTI noted a 2‑day median for WellPoint vs. 13 days for Health New England) could undermine accuracy; CTI said rapid auto‑adjudication can correlate with errors and recommended additional operational review.

GIC staff said performance guarantees in carrier contracts can result in administrative‑fee forfeitures when carriers underperform, and they will pursue remediation tracking, additional data requests and follow‑up with carriers. Staff also said some apparent noncompliance can reflect plan‑document wording rather than operational practice, and those instances will be reconciled prior to finalizing findings.

The auditors’ findings are preliminary and under discussion with carriers; CTI and CXC will update final reports and provide additional extrapolated impact analyses to commissioners at or before the December meeting. The commission signaled it expects concrete remediation plans, possible contractual enforcement, and a timeline for any off‑cycle audit results and carrier adjustments.

The GIC will receive a written update with the auditors’ extrapolated dollar estimates and a schedule of next steps in December.