Specifications include, but are not limited to: The Group Insurance Commission (GIC) of the Commonwealth of Massachusetts intends to post a Bid for a health care claims auditing services; The GIC seeks a vendor to provide health care claims auditing services for its (self-insured) health carriers. The GIC expects the successful Bidder to perform audits of the carriers’ claims processing, claims administration, management and operations. It is anticipated that the vendor will conduct audits of the GIC’s pharmacy benefit managers (PBMs) claims processing services, discount analyses and rebate administration) in year two of the contract and each following year. For all carriers, the audit should also examine other management and operational activities performed on the GIC’s behalf by the carriers (this includes behavioral health parity – see below). The GIC’s incumbent carriers are: UniCare, Point32 (parent company of Harvard Pilgrim Health Care and Tufts Health Plan), Mass General Brigham Health Plan, Health New England, and CVS/Caremark (pharmacy benefit manager). The audits take place during the winter; findings are reviewed with the staff in April and presented to the Commission at its June or September meeting. As part of the audits, the GIC expects a corrective action plan to be prepared for the carrier (as needed) based upon the carrier’s audit results. Tentatively, in FY2024 the successful Bidder would audit the FY2023 claims of two Medical carriers. In FY2025, the FY2024 claims of the remaining two medical carriers. would be audited. In FY2026 and FY2027, the successful Bidder may be asked to perform follow-up audits of the medical plans and the aforementioned prescription drug audits.
