Senate panel investigates debts owed by insurers to hospitals

Insurance commissioner says he is looking into 7 insurers that owe $5.49 million

The insurance commissioner told a Senate panel that his office’s audit of seven insurers has found that outstanding payments include $5,489,324 in claims pending payment to hospitals.

By The Star Staff

The Senate Health Committee, chaired by Rubén Soto Rivera, held a public hearing Tuesday to address the debts owed by insurers to hospitals in Puerto Rico.

“Every day I become more convinced that it is urgent to reform the payment system for health institutions and providers to improve these services in Puerto Rico and do justice to the professionals in this field,” the senator said.

Insurance Commissioner Alexander Adams Vega said his office is actively conducting an audit to investigate outstanding claims for payments to health care providers.

“During the first phase, which includes six insurers and health services organizations, it turned out that the total claims pending payments, as of July 31, 2022, were $226,368,828,” the commissioner said. “Of this amount, $101,961,593 were claims pending payments to hospitals that represented some 206,956 claims for services provided.”

Currently, the Insurance Commissioner’s office’s investigation is in Phase 2, in which they are auditing seven insurers with outstanding payments as of Dec. 31, 2022 totaling $16,302,747. Of this amount, $5,489,324 represents claims pending payment to hospitals.

On the one hand, regarding complaints from hospitals for non-compliance with the Timely Payment Law, which regulates the claims and payment process between insurers and health organizations, they discovered that Triple-S Salud Inc. maintained internal appeal processes to address disputes over payment of claims not contemplated by law.

“As a result of our investigation, an administrative order was issued to the insurer in which it was fined and ordered to desist from internal appeal procedures contrary to the Prompt Payment Law requiring it to temper its dispute processes in the law,” Adams Vega said.

Triple-S senior vice president of technology and plan management, Carmen González, noted that she pays all of her contracted suppliers in Puerto Rico around $182 million per month. She added that some 30 percent of the payments issued by Triple-S are made to hospitals.

González said 9.5 out of every 10 claims received are processed automatically in less than 30 days, through computerized systems that have been configured to comply with contracts. In addition, six percent of the institutional claims received are pending evaluation of the required documentation, and once received, it takes 10 days to issue payment.