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  • Writer's pictureThe San Juan Daily Star

Fines against health insurers in Vital Plan are on hold

Health Secretary Carlos Mellado López

By The Star Staff

The $300 million in fines imposed by the Health Insurance Services Administration (ASES by its Spanish acronym) against health insurers over their failure to pay established rates are on hold.

Health Secretary Carlos Mellado López said Monday that the parties are trying to reconcile the positions of both the government and four insurers in the context of payments for services under Medicare and Medicaid.

On June 22, Mellado announced that MMM, Triple S, Plan de Salud Menonita and First Medical, all contracted under the Plan Vital government health coverage, had been fined for allegedly failing to comply with the minimum rates established for services rendered by providers that went into effect Jan. 1.

Specifically, the contract with Medicare establishes a reimbursement of 75% for specialists and between 80% and 100% for subspecialties, in addition to a payment for 18 patients.

In the case of Triple S, a deficiency of $800,000 in payments to providers was identified and, in the cases of other companies, the deficiencies were $742,000 (Menonita) and $2.6 million (MMM and First Medical).

ASES is evaluating all the data sent by the insurers.

“Our intention is not to blame the insurers or to demonize them, but to get the money to the provider,” Mellado López said regarding the government’s intention in imposing the fines.

He said there has been good communication with the companies and that if they comply with the payments owed, “there should be no fine.”

“They can be left without effect,” the Health chief added. “They can continue until the administrative process, which has not concluded, is over.”

Mellado López has said that insurers have alleged that there have been programming problems.

ASES director: $5 million identified for payment to Vital providers

ASES Director Edna Marín Ramos announced separately on Monday that the aforementioned Vital Plan insurers have identified a total of $5 million for payment to service providers after being notified of fines for not meeting the minimum rate of the Medicare Fee Schedule (MFS).

“We are advancing in our work and we are seeing results,” Marín Ramos said. “All the insurers are processing their payments to the service providers, which was our main objective from the beginning.”

“The corrective action plans submitted ensure that specialists and subspecialists receive their 80 percent and 100 percent MFS payments, respectively,” she added.

So far, Triple S has identified close to $800,000 in retroactive adjustments. Even so, the figure continues to be reviewed since specialties that pay more than 75 percent of the MFS have been identified.

Meanwhile, the Mennonite Health Plan has shown that it has configured its system and has paid 78.3% of the reprocessed claims, which amounts to some $742,369.18 as of July 7. That leaves 21.7% of the claims still pending retroactive payment.

First Medical has identified some $2.6 million in retroactive adjustments, while MMM is making an approximate retroactive adjustment of $2.6 million, which includes adjustments to the Medical Sciences Campus of the University of Puerto Rico.

“The process for imposing fines is under review and the full compliance of the insurers will be verified by July 31, the deadline for them to present final evidence that they have complied with the contract agreements regarding payment to providers,” Marín Ramos said.

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