New York- Roberto Pando, president of the Medicare and Medicare Advantage Products Association (MMAPA), rejected the lawsuit recently filed by the entity in the federal court of Puerto Rico against the island’s Office of the Insurance Commissioner (OCS) Its purpose is to avoid inspection of insurers.
Pando argued that the appeal filed last Friday before the United States District Court for the District of Puerto Rico seeks to have the court determine that the federal government is the main entity with jurisdiction in evaluating the conduct of medical plans. of Medicare Advantage (MA) that operate in the territory.
“The Medicare Advantage program is possibly the most regulated health program that operates in Puerto Rico; the most closely monitored health program. What happens is that it is regulated and supervised by the federal government directly because basically they run a uniform process throughout the United States,” said the also president of MCS Advantage, Inc. and MCS Life Insurance Company.
MMAPA alleges that the federal government is in charge of supervising insurers
The plaintiffs’ main allegation is that, since they are federal programs, evaluating the functioning of Medicare and Medicaid on the island falls to the Centers for Medicare and Medicaid Services (CMS). According to the 13-page legal document cited by El Nuevo Día, the government of Puerto Rico through the OCS has no interference in the way in which Medicare Advantage Organizations (MAO) pay health providers.
“There are over 2,500 pages of manuals, what they call ‘Medicare Management Manuals’, that cover all the lines of operation of a Medicare Advantage plan that CMS itself; The federal government regulates, audits. All plans are audited in their operations, in the facilities; Reports are submitted on the entire operation of the plans. So when state agencies try to make rules that conflict with federal rules, there is a lot of confusion,” the executive alleged.
Do you not want to be supervised at the state level and do you want to walk freely, as the insurance commissioner suggests? El Diario asked.
“Not at all,” Pando replied. “There is an oversight in Medicare Advantage that has operated. I just mentioned the star show. There is no larger and more sophisticated results measurement program for a health plan function other than the Star Program; and there is data and data and data, and that is taken care of. So it has nothing to do (with oversight). “Medicare Advantage is scrutinized more than any other,” he argued.
Pando refers to the fact that this year, for the first time, MCS Advantage Inc. in Puerto Rico became the only health plan to receive an overall rating of 5 out of 5 stars for the 2024 contract year, by CMS for its contract of Medicare Advantage.
The lawsuit, filed by attorney Roberto Prats Palerm, from the McConnell Valdés LLC law firm, seeks to limit the intervention of Commissioner Alexander Adams’ office in terms of investigation or fines for non-compliance by insurers with the Puerto Rico Insurance Code.
“The Commissioner intends, in particular, to prohibit certain practices regarding the size and timing of reimbursements, contractual allowances, and coverage adjustments approved by CMS (Centers for Medicare and Medicaid). “These regulatory efforts broadly invade areas of exclusive federal jurisdiction with respect to benefit plans offered under the MA (Medicare Advantage) program,” reads part of the lawsuit.
MMAPA’s expectation, according to Pando, is that the court will issue a declaratory judgment establishing the extent to which the insurance commissioner has jurisdiction over these matters.
“This is an action called declaratory judgment. What is being asked of the court is that it can, in an organized manner, clarify what the jurisdiction of the commissioner is and what the jurisdiction of the federal government is, and what it does is protect the integrity of the Medicare Advantage program,” he added.
“In Puerto Rico, over $8 billion dollars a year have to be administered through this program. There are extraordinarily detailed federal rules, detailed oversight, detailed audits that exist, so what this initiative seeks is to clarify what the scope and function of the commissioner is vis-à-vis the oversight of the commissioner on the one hand, solvency and licensing , and the rest of the oversight of the program, which by law is carried out directly by the federal government and by CMS, which audits all plans,” said the interviewee.
Pando highlighted that, in accordance with the law, the commissioner has jurisdiction over two elements: the solvency of insurance companies and licensing.
“I think it is important…The Medicare Advantage program has had its year of greatest losses in the history of Puerto Rico. In Puerto Rico, at one time there were 14 Medicare Advantage plans, today there are 4,” he indicated on the matter.
The OCS is the state regulatory body for the sector. One of the main purposes of the entity is to supervise the different components of the insurance industry (producers, authorized representatives, general agents, adjusters and insurers, among others) and ensure that they comply with the provisions of the aforementioned code and regulations, as well as with the Insurance Consumer Charter of Rights and the obligations agreed upon in an insurance contract. To these ends, the OCS carries out audits and investigations, many of which are initiated by citizen complaints.
Speaking to the local newspaper this week, Adams indicated that, since last year, the OCS has carried out audits of these insurers to corroborate how solvent they are.
The investigations revealed “significant amounts in outstanding accounts” to health providers for services rendered.
“These Advantage insurers recognized the debt in their books, they had them in the ‘ready to pay’ account, but they did not make the disbursements. We are talking about sums that last year reached $246 million,” said the commissioner.
“This demand is a response to the fact that we are monitoring them,” the official considered.
At least seven organizations support the commissioner in lawsuit
Seven health organizations in Puerto Rico opposed MMAPA’s lawsuit against the office and anticipated that they will appear as friends of the court in support of the commissioner, when he is summoned.
“I have to emphasize that, historically, the College of Physicians has never, ever had a commissioner on its side. The commissioner (Adams Vega) is a friend of the doctors, of the providers,” declared the president of the College of Surgeons of Puerto Rico, Carlos Díaz Vélez at a press conference.
The Association of Clinical Laboratories of Puerto Rico (ALCPR), the Association of Hospitals of Puerto Rico (AHPR) and the Association of Community Pharmacies (AFCPR) are other entities that thundered against the action of MMAPA.
This discussion is of particular importance in Puerto Rico currently due to the crisis in the health system due to several factors that include inequity in federal funds for programs such as Medicare and Medicaid, the closure of hospitals due to bankruptcies and the delay in reimbursements to providers for part of the insurers, among others. The above translates into the reduction of medical personnel on the island to care for an increasingly aging population.
In 2020 there were around 19,000 doctors on the island. By 2023 there were fewer than 9,500 doctors with active licenses left. Of that number, 6,400 are specialists, according to data managed by the Center for Investigative Journalism (CPI).
Pending the next part of the interview with Pando in which we address the movements in Congress to achieve equity in the Medicare Advantage program in Puerto Rico as a measure to alleviate part of the crisis of the system in Puerto Rico and the flight of doctors.
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