GICPND1601 Notice of Intent.docx

NOTICE TO HEALTH CARE CLAIMS AUDITORS

AND OTHER INTERESTED PARTIES

August 21, 2015

This is an announcement only. The Group Insurance Commission (GIC) of the Commonwealth of Massachusetts intends to post a Bid for health care claims auditing services and to require online Quote submission via the Commonwealth’s COMMBUYS system. Bidders are solely responsible to monitor this site for amendments to this announcement and for the complete Bid posting. Bidders may monitor the site through publicly accessible search and browse tools, or through COMMBUYS email notification and record tracking tools by ensuring the commodity codes associated with this record are included in the commodity codes section of their COMMBUYS profile. Bidders may elect to subscribe to COMMBUYS immediately or wait until they have reviewed the complete Bid posting including the RFR and any amendments. Bidders who elect to establish a COMMBUYS account must select the Register link on www.commbuys.com and complete the online subscription process. Bidders for this RFR should include Commodity-EPP codes 80-10-00-00 (Management Advisory Services), 84-11-00-00 (Accounting and Bookkeeping Services), 84-13-16-08 (Medical Claims Review and Management), or 85-10-17-07 (Health systems Evaluation Services) in their COMMBUYS profile.

The GIC seeks a vendor to provide health care claims auditing services for its self-insured and fully-insured health carriers. The GIC expects the successful Bidder to perform audits of the carriers’ claims processing, claims administration management and operations. For the GIC’s pharmacy benefit manager (PBM), the engagement includes an audit of the PBM’s claims processing service, discount analysis and rebate administration. For all carriers, the audit should also examine other management and operational activities performed on the GIC’s behalf by the carriers. The GIC’s incumbent carriers are: UniCare Life and Health Insurance Company, Harvard Pilgrim Health Care, Tufts Health Plan, Fallon Health, Health New England, Neighborhood Health Plan, CVS/Caremark (pharmacy benefit manager) and Beacon Health Options (mental health/substance abuse plan). The audits take place during the winter; findings are reviewed with the staff and presented to the Commission at its June 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. The successful Bidder will audit the GIC’s carriers over a two-year period (during FY2016 and FY2017). Tentatively, in FY2016 the auditor would audit Beacon Health Options, CVS/Caremark, Harvard Pilgrim Health Care and Tufts Health Plan. The remaining plans would be audited in FY2017. The successful Bidder may also be asked to perform a follow-up audit of each carrier, which would be conducted two years after the initial audit cycle (in FY2018 and FY2019).

Respondents should have substantial experience in auditing health care claims processing and the financial accuracy of large health insurance carriers and pharmacy benefit managers, using the audit process to evaluate claims processing and/or management concerns identified by previous audits or GIC staff, assessing claims processing performance (including, but not limited to, financial accuracy) against industry and contractual standards and in auditing pharmacy rebate administration. Potential vendors are expected to either possess both the medical and pharmacy claims audit expertise in-house or to Bid in partnership with a complementary firm.

Established in 1955, the GIC is a quasi-independent public agency, providing benefits to approximately 435,000 employees, retirees, survivors and dependents of the Commonwealth of Massachusetts, and certain other public and municipal entities. In FY2015, the GIC spent approximately $2.6 billion to provide health care benefits to this population.

The full text of the Request for Response (RFR) may be obtained via the Internet on or about September 9, 2015 using the Commonwealth’s COMMBUYS system. COMMBUYS is located at www.commbuys.com. The file number for this RFR is BD-16-1049-GIC00-07GIC-00000005281. Its title is, “GICPND1601 Procuring Auditing Services for Health Care Claims Processing and Related Activities for the Group Insurance Commission”. Questions regarding the RFR should be directed to Catherine Moore, Budget and Research Director for the GIC, at (617) 727-2310 x7033 or via email at catherine.moore@gic.state.ma.us. The RFR will state the schedule and definitive due date for responses, tentatively set for October 7, 2015. A bidders conference, to be held after the RFR is released, is tentatively set for September 17, 2015.

The GIC reserves the right to reject any or all responses or to accept any proposal or portion thereof, if deemed to be in the best interests of the Commonwealth and its insureds.

Dolores L. Mitchell Executive Director Group Insurance Commission