Government

ASES finds $9.7M in duplicate payments to health plans

ASES Executive Director Ricardo Rivera. ASES Executive Director Ricardo Rivera

The Puerto Rico Health Insurance Services Administration, or ASES in Spanish, stands to recover about $9.7 million in duplicate payments made to insurance companies for services provided to patients covered by the government’s health plan, agency Executive Director Ricardo Rivera said Monday.

The amount was revealed through an audit the agency commissioned earlier this fiscal year, he added.

“It is our responsibility to ensure that funds to provide services to the 1.7 million government health plan beneficiaries are well used and that disbursements we make correspond to the billed services,” he said. “Overseeing funds and processes is one of my team’s main goals, so as soon as I arrived to ASES, I asked for different audits.”

The first such review targeted transactions conducted during the 30 months prior to his January 2013 appointment.

“This analysis showed that the administrative processes, specifically in the area of billing, were deficient, which gave way to millions in improper payments. When I became aware of this, I asked for a second audit to analyze payments made over a five-year retrospective period starting in 2011,” Rivera said.

The first audit reflected duplicate payments reaching $2.8 million in transactions between January 2011 and June 2013. The second reflected duplicate payments of $6.9 million from January 2006 to December 2010. A total of 22 organizations that provided services to the government health plan were audited, either for physical, mental, or Medicare Platinum coverage, he explained.

The findings showed that many of the duplicate payments were made because there were changes in family composition, or insured who changed region, among others. Of the more than 100 million transactions analyzed, about 500,000 will have to send money back to ASES, he said.

Meanwhile, he said the audit process also enabled ASES to identify vulnerabilities in its processes, which prompted implementing a corrective action plan to “identify, prevent and mitigate the risks of improper payments in the billing process.”

“We standardized intervention processes, for which ASES specialists corroborate the specific documentation required, by area and by type of bill, prior to approving any disbursement,” he said. “We are also strengthening our information system to incorporate all the necessary controls to identify these improper payments. I am confident that the new system will be ready for the end of this fiscal year.”

There are about 15 additional audits underway, both internal and external, whose results will be released once they are completed, Rivera said.

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