Insurance commissioner launches probe into health insurers’ physician credentialing practices
By THE STAR STAFF
Puerto Rico Insurance Commissioner Suzette del Valle Lecároz announced Monday that her office is intensifying oversight of physician and healthcare provider credentialing processes amid growing complaints about duplicate documentation requests, additional requirements and delays by health insurers.
The Office of the Insurance Commissioner (OCS by its initials in Spanish) has already opened an investigation into the procedures used by health insurance companies to credential and contract healthcare providers, following concerns raised by physicians and other healthcare professionals.
“We recognize the concerns and frustrations expressed by physicians and other healthcare professionals regarding the difficulties they face during credentialing and contracting processes with health insurers,” del Valle Lecároz said.
The commissioner noted that Act 73 of 2023 was enacted to streamline and standardize the credentialing process, reduce paperwork duplication and make it easier for healthcare providers to obtain credentials. As part of the law’s implementation, OCS administers the Online Credentialing System, or SICRO by its acronym in Spanish, a centralized platform that allows providers to submit required information and documentation through a uniform application that can be accessed by health insurers.
Del Valle Lecároz said the law establishes specific obligations for insurers. Health plans must use the Uniform Credentialing Form and cannot require providers to submit information beyond what is included in that application. Insurers are also required to notify providers of any deficiencies in their submissions within 15 days and complete the credential verification process within 30 days of receiving a properly completed application.
“The legislation establishes clear obligations for health insurers, and it is our responsibility to enforce them,” del Valle Lecároz said.
The commissioner also emphasized that contracting and provider network participation decisions remain internal processes of health plans and are separate from credentialing. However, she warned that insurers cannot use those contracting processes to circumvent the requirements imposed by law.
As part of the investigation, OCS plans to summon health insurers to review their practices, reiterate their obligations under Act 73 and require the elimination of procedures or requirements that conflict with the statute.
“Recent reports of duplicate documentation requests, additional requirements and potential unjustified delays in contracting processes are of concern,” del Valle Lecároz said. “We will be examining these practices closely.”
The commissioner warned that health plans found in violation of Act 73 could face administrative fines ranging from $500 to $10,000 per violation. She said OCS will use its enforcement authority to ensure compliance and address practices that may be affecting healthcare professionals.
Del Valle Lecároz argued that a more efficient credentialing process could also help strengthen provider networks and improve patient access to medical services.
The commissioner encouraged physicians and other healthcare providers experiencing problems with credentialing, including requests for unnecessary documents, duplicative requirements or unreasonable delays, to contact OCS and report their concerns.
“We are committed to enforcing the law and ensuring that credentialing processes operate in an efficient, transparent manner and without unnecessary administrative burdens,” she said.
