Federal judge sends PR labs’ reimbursement dispute back to local court.
- The San Juan Daily Star
- May 13
- 2 min read
Ruling comes as Medicare Advantage funding set to rise
By THE STAR STAFF
Puerto Rico’s clinical laboratory association is calling for tighter oversight of Medicare Advantage spending after federal officials projected a significant funding increase for the island’s plans in 2027, even as the group continues a legal fight over what it says were steep, unilateral reimbursement cuts by an insurer.
The Puerto Rico Clinical Laboratories Association (ALCPR by its initials in Spanish) said the federal increase amounts to more than $561 million in additional payments to Puerto Rico’s Medicare Advantage program for contract year 2027, serving some 679,000 beneficiaries on the island.
ALCPR President Felipe Cintrón Zayas credited Gov. Jenniffer González Colón and Resident Commissioner Pablo José Hernández Rivera, along with a broader health-sector coalition, with helping secure a 4.01% Medicare Advantage rate increase for Puerto Rico -- above the average national increase cited by local officials.
The ALCPR’s announcement comes after a ruling from the U.S. District Court in Puerto Rico that sent the association’s lawsuit against Triple-S Advantage and Triple-S Salud back to Puerto Rico’s state court system. The ALCPR argues that the companies imposed reimbursement reductions of up to 25% on labs serving Medicare Advantage members.
Clinical laboratories say they are facing mounting financial pressure as insurers expand into operating clinics and in-house lab services while also negotiating lower payments to independent providers.
“Any increase in Medicare Advantage payments should translate into better access, compliance with federal rules, and fair payments,” Cintrón Zayas said in a statement. “It can’t simply become higher profit margins for insurers while the lab network that serves patients every day is weakened.”
Among its recommendations, ALCPR urged stronger audits of Medicare Advantage plans’ Medical Loss Ratio reports for 2027 -- aimed at confirming that the new federal dollars are spent on medical care, including provider payments, rather than administrative costs. Under federal rules, plans generally must spend at least 85% of certain revenues on medical care and quality improvements.
Cintrón Zayas also called on the U.S. Department of Health and Human Services’ Office of the Inspector General to include Puerto Rico in Medicare Advantage compliance audits, pointing to the agency’s recently updated Medicare Advantage compliance program guidance released in February of this year -- the first major update since 1999.
The ALCPR noted that a large share of medical decisions depend on laboratory testing, arguing that sustained cuts could affect access to diagnostics.
Triple-S dispute back in island court
In court filings, Triple-S argued the dispute belonged in federal court because it involved Medicare Part C (Medicare Advantage) requirements. The ALCPR, however, says Puerto Rico contract law bars one-sided changes in so-called adhesion contracts, and that the case should be decided under local law.
“The [federal court’s] ruling means the question of whether reimbursement rates can be modified unilaterally will be resolved where it belongs -- before Puerto Rico courts,” Cintrón Zayas said.
The dispute centers on Triple-S’s move last year to change its lab payment methodology from a percentage of the 2016 Medicare fee schedule to a percentage of the 2025 Medicare fee schedule, which the ALCPR says resulted in payments that did not cover the cost of services
Drift boss is simple to learn but hard to get good at. You can move through endless platforms with simple one-tap controls, making sure you don't fall and keep the right drift timing. It's important to know when to drift and when to go straight!