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Lawmakers press Blue Cross on Cotivity vendor, review staffing and $15 million in adjustments
Summary
Committee members questioned Blue Cross about the vendor Cotivity's role, whether reviews use AI or manual crosswalks, specialty matching of reviewers, and how the committee should interpret a roughly $15 million adjustment figure for a six-month period.
Members of the House Insurance Committee spent substantial time after the Blue Cross presentation pressing the insurer on vendor processes, reviewer expertise and the arithmetic behind reported adjustments.
A member asked how many providers were in the outlier cohort; Blue Cross said 14% of its network — roughly 4,000 providers out of 39,000 — initially met the outlier threshold. When asked who reviews flagged claims, witnesses said Cotivity performs the first-line review using a crosswalk algorithm and clinician reviewers (nurses and physicians) evaluate records; on appeal, Blue Cross uses clinicians again. Committee members asked whether Cotivity or the review process employs AI; witnesses repeatedly said the described edit predates machine-learning deployment and is not an AI model.
Committee members also walked through the arithmetic. The panel discussed 552,000 adjusted claims and an average $31 impact per adjusted claim; committee members multiplied those figures and agreed the adjustments generated approximately $15,000,000 between April 15 and Dec. 31. Blue Cross said the figure covered the April–Dec. 31 period and not a full year and that appeals had reversed some adjustments.
Lawmakers asked for follow-up documents breaking out the same metrics for TennCare and for the committee to examine whether automation has changed human reviewers' framing of claims. Blue Cross agreed to provide additional data and said the vendor has used the crosswalk edit since about 2006.
