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  • Writer's pictureThe San Juan Daily Star

Health Dept. to review medical insurance contracts to ensure compliance

Health Secretary Carlos Mellado López

By The Star Staff

Health Secretary Carlos Mellado López announced on Monday a review of all medical insurance contracts with providers to ensure health insurers pay costs agreed upon to doctors.

Mellado said he wanted to achieve a satisfactory solution to various situations that have put the health system in Puerto Rico at risk and ordered insurers and medical groups to “comply with rates and payments to providers.”

“In keeping with the priority of the governor, who has been emphatic about improving the public health scenario, I have focused on creating a fair environment, both for health service providers and for patients, Mellado said. “The increase in the fee is clear and is aimed at our primary physicians, specialists and subspecialists, which translates into direct service for our people. However, medical groups and insurers have been hampering the efforts of this administration. Therefore, I have ordered ASES [the commonwealth Health Insurance Administration] to redouble inspection efforts to ensure proper compliance with contracts.”

The Health secretary noted that they will review contracts and interview providers this coming week. He said medical providers or health insurers that are not in compliance may have their contracts canceled.

“My call to these groups is to make the adjustments before we reach them,” Mellado said, after stressing that “the money is not for the insurers or for the owners of IPAs [independent practice associations].”

Mellado has been advocating in Washington, D.C. for more funding in Medicaid and other federal funds. He has had fruitful meetings with U.S.Health and Human Services Secretary Xavier Becerra, Rep. Nydia Velázquez (D-N.Y.), Sen. Ron Wyden (D-Oreg.) and several members of Congress who share the vision of prioritizing the island’s medical needs.

However, in achieving parity of funds and improving the health system, Mellado has urged insurers to support the medical class, with control being more rigorous than ever.

“Insurers play an important role in our health system, but the goal always has to be the patient and fair payment to providers. The federal funds we receive through the Medicaid program belong to the patients,” he said. “We cannot allow private for-profit companies to continue running over suppliers, depriving them of fair payment for their services, with the ultimate goal of continuing to generate money. The insurers must comply with the fixed cost per patient that was agreed upon.”

The health chief has pointed out that this is the first administration since the Health Reform began in 1994 that has given priority to fair payment to health service providers, and equates them in importance to the services provided to patients.

“With far-reaching changes in the payment model for our providers in the new Plan Vital contract, we increased the fee per patient per month for primary physicians from $12 to $18 and raised the Medicare Fee Schedule from 70% to 80%,” Mellado said.

Also, with the additional funds for which the administration of Gov. Pedro Pierluisi Urrutia has worked, rates for specialists, and some subspecialists where there are critical access problems, were raised to 100% and the Medicare Fee Schedule for hospitals was increased by 5%. This is the highest rate paid at the state level and is reviewed annually, the Health chief said.

Mellado further pointed out that it is important to keep petitioning the federal government to continue mitigating the inequities in funding.

“We continue the fight to leave disparities behind,” he said. “We want our patients to receive the best services, fair compensation to our medical class and to have a first-class healthcare infrastructure.”

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