Patient complaints spur meeting to resolve dispute between gov’t & insurer

Sen. Keren Riquelme Cabrera

By The Star Staff

In view of the thousands of complaints from users of the First Medical Health Services health plan about the provision of medical services, Sen. Keren Riquelme Cabrera has summoned to a meeting, as a matter of urgency, the directors of the insurer that provides services to the government’s Vital Plan, as well as officials from the Puerto Rico Health Insurance Administration (ASES by its acronym in Spanish) and island Health Secretary Carlos Mellado López.

The meeting is scheduled for next Tuesday, July 16, at 10 a.m.

Riquelme said cases have already been reported in which doctors have informed their patients that they will not evaluate them further until the dispute between the parties is resolved.

“Since July 1, we have received dozens of calls from constituents who use the government’s health insurance plan, Plan Vital, through the insurer First Medical, who are afraid that they will be refused visits and treatments, among other services,” the senator said. “ASES was clear when it indicated that First Medical was in default; however, the insurer has indicated that it is ASES that owes it money, so we are all going to sit down at the same table so that this problem is resolved before it continues to affect people and their appointments.”

On July 1, ASES sent a notice of non-compliance to First Medical Health Services, particularly around Articles 19 and 20 of the contract signed by the insurer with the Vital Plan, in reference to multiple allegations of non-payment to medical service providers.

Days later, First Medical, which currently provides services to some 291,000 Vital Plan beneficiaries, responded by alleging that ASES owes it more than $85 million in retroactive premiums pursuant to amendments signed by both parties to the Vital Plan contracts in order to adjust premiums.

“Here there are two opposing positions, and in the middle hundreds of thousands of lives who use First Medical for their basic medical services,” Riquelme said. “It is specifically the beneficiaries that we seek to protect and the reason for this meeting; we want both First Medical and ASES to present us, with detail and documentation, their positions and together seek a solution that prevents services from being suspended.”