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Redacted by Vilmar Trinta | Interviewed Attorney Tomás Hernández, Contracting and Provider Relations Director
The Health Insurance Administration (ASES) will officially begin the implementation of the APR-DRG system (All Patient Refined Diagnosis Related Groups) on January 1, 2026, which will replace the current per diem payment model for hospitalizations. This change marks a significant transformation in how hospital services are calculated and reimbursed under the Plan Vital program, impacting hospitals, medical groups, and independent providers alike. 
Attorney Tomás Hernández, Contracting and Provider Relations Director, explained that this new model seeks to “adjust payments more equitably, based on the patient’s clinical complexity—not merely on the number of hospitalization days.” According to Hernández, the goal is to promote a more efficient and transparent system where quality of care and clinical documentation play a decisive role in final compensation. This shift requires greater precision in coding and strict compliance with clinical criteria.
“The APR-DRG groups hospitalizations according to the principal diagnosis, procedures performed, and the patient’s level of severity or risk. Each combination translates into a rate per episode of care. This means the focus changes—payment is no longer per day but for the entire clinical management of the patient during their hospitalization,” Hernández explained.
The APR-DRG system introduces a prospective payment structure, in which each hospitalization is assigned a standardized rate determined by its diagnostic group. This demands detailed and accurate clinical documentation, as any omission or inadequate coding can directly affect the final payment. 
Hernández cautioned that “accurate medical coding and documentation will be critical. If a diagnosis or procedure is not properly reflected in the patient’s record, the system may assign a lower severity level, resulting in a reduced payment. In other words, the quality of the recorded information will directly impact the compensation received.”
“In the APR-DRG model, it is important to note that not all medical services are included: outpatient services, professional services rendered outside the hospital setting, and procedures not covered by the health plan are excluded,” the director added.
For medical services to be billable under this model, they must be clearly documented, meet clinical criteria, and be provided by duly contracted and credentialed professionals.
This means that physicians must complete rigorous credentialing processes and formalize contracts with insurers in order to be active participants in provider networks.
The attorney also stressed that the absence of a formal contract or valid credentialing may result in services not being recognized or reimbursed, which could affect both patient care continuity and the physician’s financial stability.
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