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Independent audit finds low overall claim error rates but flags systemic issues and overpayments across carriers
Summary
CTI presented FY23 claim-administrator audits of Harvard Pilgrim, Mass General Brigham and Tufts, reporting high overall financial accuracy but identifying systemic adjudication errors, duplicate or excluded-service payments and recommended focused carrier remediation, impact reports, and contract language to recover overpayments.
An independent claim-monitoring audit presented to the Group Insurance Commission (GIC) found high overall financial accuracy among the three audited carriers but identified a set of processing errors and systemic issues that the auditor recommended the commission and carriers address.
Marie Pollock, director of audits at CTI, told commissioners the FY23 audit used a statistically valid random sample (200 claims per carrier), a 100% electronic screening of the full claim population and a targeted 150-claim review. The audited period covered services incurred July 1, 2022 through June 30, 2023 (paid through Dec. 31, 2023).
CTI reported the following sample…
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