According to an article on February 18, 2014, by “El Nuevo Día”, the Health Insurance Administration (“Administración de Seguros de Salud” or ASES) will try to recover 9.7 million dollars, for payments made twice to twelve insurance companies. These insurance companies provided services to beneficiaries of “Mi Salud” and “Medicare Platino”. During an audit, from January 2011 to June 2013, ASES noticed that they had paid insurance companies twice during that period for a total of 2.8 million dollars. The audit was extended to 2006. Ricardo Rivera, the Executive Director of ASES, expressed that irregularities were discovered in 500,000 of the 100 million transactions that were analyzed. According to Rivera, the double payments from ASES are because of two irregularities: 1) beneficiaries who change address and region, but are still register under a different region and 2) beneficiaries who change their family’s composition, but are still registered under their previous family composition, for example a son who marries and now has a new family composition, still register under the family composition he had with his parents and siblings.
Among the insurance companies who were paid twice are: MMM, Humana, PMC, American Health, APS, Cosvi, FHC, Mapfre, First Medical, “Salud Dorada”, Triple-S and MCS. Most of the double payments, around 3 to 4 million dollars, were paid to Triple-S and MCS. Rivera indicated that these results are only from 16 audits that “Mi Salud” is currently under, since March 2013.
To recover the 9.7 million dollars, originally 13 million, ASES will make deductions from these insurances companies’ premiums, since they have contractual relationships with the administration. 84% of these double payments are intended to be recovered this way, while the remaining 16% will be recovered through formal procedures.
Rivera indicated that the information system currently used by ASES is not prepared to detect when an insurance company is paid twice, this task is done manually, verifying each invoices with a list of beneficiaries according to the different regions. ASES hopes that in the next years these transactions are made electronically. Rivera expressed that “it is our responsibility to safeguard that the funds destined to provide services to the 1.7 million of beneficiaries from PSG (and “Medicare Platino”) are correctly used and that the payments made correspond to the services billed.” He also indicated that measures have been taken, through a plan of corrective action, to identify and prevent the risk of emitting incorrect payments when billing.
It is unbelievable, that while the country is undergoing an economic crisis, the Government is paying insurance companies twice. While insurance companies receive a double payment, the patient continues to pay an extremely high premium for a health care plan and continues receiving the same quality of medical treatment, which sometimes is awful. How is it possible that ASES failed to notice that it was emitting a payment twice, for the same person, to a same insurer? The same applies to the insurers. How is it possible that they failed to realize they were receiving a payment twice for a same person and for a same service?
We hope the ASES manages to recover the 9.7 million dollars it has paid the insurance companies in excess and that this mistake does not affect the beneficiaries of “Mi Salud” and “Medicare Platino” and the patients in Puerto Rico.