$4 Billion in Federal Health Care Funds Saved for Puerto Rico

Record of SuccessA health care provider in Puerto Rico was struggling to increase Medicare reimbursement rates. In an effort to maintain operations and provide medical services to the island’s residents, the provider engaged National Health Advisors for help. 

The Commonwealth of Puerto Rico faces unique circumstances for federal health programs. The residents of Puerto Rico are U.S. citizens and participate in Medicare, but they are not automatically enrolled in Medicare Part B, resulting in low participation. In addition, Puerto Rico does not receive disproportionate share hospital payments and U.S. citizens living on the island do not receive Supplemental Security Income benefits. As such, the fee-for-service (“FFS”) cost calculation for Puerto Rico is artificially low. 

The Puerto Rican Medicare Advantage market has evolved to become the highest penetration by far in the United States. The FFS cost must be calculated accurately to ensure that Medicare Advantage providers are reimbursed at the proper rate. Failing to do so would cost Puerto Rico’s health care system billions of dollars and deprive U.S. citizens living on the island of affordable health care choices.

National Health Advisors worked with key members of Congress, including members of the House Ways and Means Committee, the House Energy and Commerce Committee, and the Senate Finance Committee, during the legislative process of the Affordable Care Act.  Additionally, National Health Advisors engaged high-ranking officials at the Department of Health and Human Services and Centers for Medicare & Medicaid Services to resolve low FFS rates through regulatory relief.

Through a combination of legislative and regulatory solutions, National Health Advisors succeeded in having Puerto Rico’s FFS rates calculated more accurately, thus ensuring that reimbursement rates for Medicare Advantage programs would be fair.  The end results were savings of approximately $4 billion in federal health care funds that would have left Puerto Rico’s health care system had it not been for the efforts of National Health Advisors.

NHA is affiliated with the law firm of Epstein Becker & Green, P.C., which has a health care and life sciences legal practice that is among the nation’s largest.

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