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Interview with Sandra V. Peña Pérez, PT, MHSA, Chief Officer of Claims Administration and Information Systems Operations at Plan de Salud Menonita
The implementation of the APR-DRG model in Puerto Rico marked a significant transformation in the hospital payment methodology under the Medicaid program administered by the Puerto Rico Health Insurance Administration (ASES). In this post-implementation stage, Plan de Salud Menonita (PSM) highlighted advances in coordination, technical preparedness, and support for hospitals as part of a structured process to ensure an effective and sustainable transition to the new model.
Sandra V. Peña Pérez, Chief Officer of Claims Administration and Information Systems Operations at Plan de Salud Menonita, led the implementation and served as an APR-DRG specialist, coordinating technical and operational teams throughout the process.
“Plan de Salud Menonita has a professional team with extensive knowledge of the healthcare industry and, specifically, of the DRG methodology, so receiving, analyzing, and interpreting the guidelines issued by ASES in order to implement the Medicaid APR-DRG payment methodology was an organic process,” Peña Pérez stated.
The executive explained that the insurer adapted its systems to the requirements established by ASES, established direct communication with hospitals, and coordinated a testing plan aligned with the official guidelines, ensuring that each institution was prepared for the new payment model.
Among the main initiatives that facilitated the transition were: 
- Creation of claims testing plans.
- Coordination meetings with medical faculties and administrative staff.
- Orientations on the changes in the payment methodology.
- Publication of circular letters on specific topics included in the ASES guidelines.
- Consolidation of all updated instructions into a Provider Guide.
Peña Pérez explained that hospitals faced challenges related to coding, billing, and payment impacts. To mitigate these challenges, PSM established a working group dedicated to the change in methodology, responsible for anticipating critical aspects and providing technical support.
“PSM dedicated a working group specifically to the change in payment methodology. This group was responsible for identifying potential challenges for hospitals, whether related to coding and billing elements or to payment impacts,” she added.
Constant communication with administrative personnel, health information management professionals, and billing teams was key. This organized exchange of information allowed hospitals to be prepared at the time of implementing the APR-DRG model, strengthening both clinical and operational coordination.
Looking ahead, Plan de Salud Menonita will continue with the monitoring and stabilization phases, providing timely updates regarding any situation that may affect processes or expected payments. Peña Pérez emphasized that educational efforts will continue so that the information issued by ASES is shared with hospitals in an agile and transparent manner.
The implementation of the APR-DRG model not only represents a change in the payment methodology but also strengthens collaboration between the insurer and hospitals, optimizes administrative processes, and contributes to the sustainability of healthcare services under Medicaid in Puerto Rico.
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