Senate panel investigates handling of federal healthcare funds in PR.

Sen. Juan Oscar Morales Rodríguez

2nd hearing focuses on unpaid insurance claims & their effects

By THE STAR STAFF

The Puerto Rico Senate Health Committee, chaired by Sen. Juan Oscar Morales Rodríguez, convened its second public hearing earlier this week as part of the investigation mandated by Senate Resolution 431.

Authored by Morales, the resolution calls for an in-depth evaluation of how federal funds are used, managed, and overseen within Puerto Rico’s healthcare system.

The investigation centers on the allocation and use of some $19.5 billion in federal funds provided by the United States Congress.

Guided by the provisions of the resolution, the committee is analyzing several critical aspects, including: whether insurers are fulfilling their payment obligations, the implementation of services as required under federal guidelines, the adequacy of the provider network, denial of contracts or service, and the consequences of those decisions on the delivery of health services throughout Puerto Rico

As part of the evidence examined, the committee reviewed information about outstanding balances owed by the insurers participating in the Vital Plan to the University Hospital at the Medical Center in Río Piedras. The data revealed that the debts exceed $27 million, with specific amounts identified for each insurer: First Medical owes some $9,381,807.77; Triple-S, $8,984,555.66; MMM Healthcare, $5,031,322.11; and Mennonite Health Plan, $3,691,809.50.

Additional data presented to the Senate panel indicated that a significant portion of claims at the Medical Center remain unpaid for extended periods. The total amount of outstanding claims is $9,648,906, with a substantial share overdue by more than 120 days. The situation directly affects the hospital’s financial and operational stability.

During Tuesday’s second public hearing, representatives from First Medical Health Plan, MMM Holdings, Mennonite Health Plan and Triple-S Salud provided testimony. They discussed the operation of the coordinated care model under the Vital Plan, the management of public funds, and the regulatory compliance measures that govern their activities.

The entities acknowledged the complex regulatory framework that governs the system, including oversight by both state and federal agencies. They highlighted metrics such as the Medical Loss Ratio, which mandates that the majority of funds be directed toward medical services. The representatives said their processes for awarding and paying claims are consistent with contractual and regulatory requirements, with controls in place to ensure traceability and proper use of resources.

Despite those assurances, the hearings have identified areas requiring further scrutiny. They include the effectiveness of the coordinated care model in practice, the distribution of funds within the system, the capacity of the provider network to meet service demand, and the financial health of hospital institutions.

Morales emphasized that the investigation’s goal extends beyond examining the system’s regulatory framework. The primary objective, he said, is to assess the actual performance of the system and its tangible impact on the public.

“Here, we are evaluating whether the system is fulfilling its fundamental purpose, which is to guarantee access to adequate and timely health services for our people,” Morales stated.

The senator also highlighted the magnitude of public funds involved, stressing the need for ongoing and rigorous legislative oversight.

“When we talk about $19.5 billion in federal funds, we are talking about a significant investment in the health of the island,” he said. “That level of resources carries with it an equally significant oversight responsibility. Our duty is to ensure that every dollar is being used effectively and that its impact is reflected in patients, providers, and the stability of the system.”

Morales noted that the committee will continue to evaluate and compare information submitted by all sectors within the health system, including hospitals, providers and other relevant entities.