ASES seeks to recover $ 23 million disbursed to insurers

The Health Insurance Administration (ASES) paid around $ 23 million “improperly” to insurers that offer service to the Puerto Rico government’s Vital plan, and is preparing to recover them during the next five weeks after concluding, through an audit, that said disbursements did not correspond to services rendered.

“One of the biggest points that has been consistently flagged for concern by Congress, CMS (Centers for Medicare & Medicaid Services), and GAO (United States Government Accounting Office) has been how strongly and precision ASES has proceeded to recover or recover sums of money that are paid to insurers for premium payments, but which are paid improperly, “said Jorge Galva, executive director of ASES, in an exclusive interview with El New day.

The official explained that the audit covered the billings processed from the start of the Vital plan, on November 1, 2018, until last summer. He also said that this process had started before, but was interrupted in mid-2019 because a contract with the company Medrx360, which carried out the audits, was not renewed.

The government entity entrusted by law to oversee the performance of insurers and the proper use of Medicaid funds allocated for the administration of the government health plan did not audit for a year, in part, because the Office of Management and Budget ( OGP) did not promptly respond to a request for contract approval, according to Galva.

“I immediately arrived at the agency, I took on the task of renewing the contract as soon as possible,” said Galva, who was appointed, in December 2019, but it was not until the middle of last year that the renewal was finalized. “OGP took months to approve the contract,” he said.

Of the approximate sum of $ 23 million, the ASES had secured, at the time of this interview, the recovery of $ 5 million already reconciled with the insurers. Galva specified that the recovery mechanism would consist in that, in the October premium payment, a deduction would be made of the amount of money to be recovered from each of the insurers.

The recovery includes the four companies that currently offer services to Vital beneficiaries -First Medical Health Plan Inc., MMM Multihealth, Triple-S Salud and Plan de Salud Menonita- and Molina Healthcare of Puerto Rico, which since November 1 2020 came off the deck.

Galva indicated that using the term “undue” when referring to payments does not imply that any illegality has been mediated, but rather that, when comparing the list of beneficiaries through an audit, it was determined that there are disbursements that do not correspond. “For example, beneficiaries move from Puerto Rico, or die, or acquire a job and become ineligible for Vital coverage and, therefore, it is necessary to constantly review the premium payment process and contrast it against the list of beneficiaries and, then, adjust the payment in a congruent way ”, he stated.

He emphasized that ASES has the primary responsibility to monitor, verify and reconcile with the insurers for the recovery. “Ultimately, you have to determine what is the amount of money that really needs to be recovered,” he said.

In addition to the $ 5 million already reconciled with insurers, ASES aims to recover up to an additional $ 18 million in the next four to five weeks.

“It is about the recovery of similar games. Each of these items has to be evaluated and reconciled with the insurers. In the case of the $ 5 million, the reconciliation has already occurred. The expectation is that the vast majority of these $ 18 million will also be recovered, ”he said.

Although it ruled out illegal payments, Galva acknowledged that, in keeping with its legal obligations, the ASES is updating and strengthening the service coordination processes to avoid deficiencies that result in statutory violations. Under both federal and state law, the official explained, Medicaid is a secondary payer or the last payer in cases of beneficiaries eligible for dual coverage or who have more than one coverage.

“It means that, if there is any insurance that covers the health needs of an insured, that insurance covers first and, if for whatever reason, the insured has health insurance from the government of Puerto Rico, then Vital enters last After that primary insurance covers the cost primarily for the health service, ”he said. “We have a legal obligation to establish cases in which there has been poor coordination and the Vital plan has ended up paying first, rather than second or last.”

Insurers react

In response to this process, Triple-S maintained that the recovery is an ordinary procedure. “ASES has not requested a recovery from Triple-S for improper payments. What does occur in the ordinary course of administering Medicaid funds is reconciliation to determine the eligibility of beneficiaries to the program. ASES communicates the reconciliation to insurers, and may lead to premium payment adjustments, both up and down. It is a dynamic, continuous and natural process that is the result of membership reconciliation, ”the company said in written statements.

The Mennonite Health System reacted in the same direction. “ASES audits of all insurers that administer the Vital Health Plan are part of the agency’s ordinary contractual processes. Since day one, the Mennonite Health Plan has worked in collaboration with ASES to comply with all contractual requirements, ”said Myriam Aguilú Cartagena, the main Communications Officer of the System.

For its part, MMM Multihealth stated that the recovery is aimed at service providers and that the insurer is the way through which the action is specified. “ASES conducts audits to the processes of adjudication and payment of claims to providers and, if discrepancies or errors are found with the payment rules established for the Vital program, particularly in the coordination of benefits when the patient has several insurance coverage, ASES determines a recovery to the provider through the insurer that, as required by them, is referred to ASES, ”said Solange De Lahongrai, vice president of MMM Multihealth.

“At no time have we been notified, nor are we aware of recoveries by ASES related to improper payments to MMM for actions or omissions on our part,” he said.

No comments could be obtained from First Medical or Molina Healthcare.

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