Colombia’s Healthcare System Grapples with Rising Health Claim Reopenings
Table of Contents
- Colombia’s Healthcare System Grapples with Rising Health Claim Reopenings
- Persistent Dissatisfaction Drives Reopenings
- Surge in Claims and Closure Rates
- EPS Facing the Highest Reopening Rates
- Claim Rates Vary Significantly Across Providers
- Special and Exceptional Regimes Show Stronger Closure Rates
- Intervention Status Impacts Claim Performance
- Superintendent Calls for Effective Solutions
Despite significant progress in resolving health complaints, a concerning trend of reopened cases is emerging in Colombia, highlighting persistent challenges within the nation’s healthcare system. A recent report from the National Superintendence of Health revealed that 0.55% of health claims – totaling 6,840 cases – were reopened as of August 2025, indicating a recurring dissatisfaction among users even after initial resolutions.
Persistent Dissatisfaction Drives Reopenings
The data underscores a fundamental issue: while the majority of complaints are addressed, a substantial fraction of patients feel their concerns weren’t adequately resolved the first time, prompting them to demand further review. This cycle of reopening claims places a strain on resources and points to systemic weaknesses in the initial assessment and resolution processes.
Surge in Claims and Closure Rates
Between January and July 2025, a total of 1,187,759 claims were filed against health promoters (EPS) across Colombia. Notably, 990,322 – representing 83.3% – have already been closed. The Superintendence attributes this progress to ongoing monitoring efforts with both communities and EPS, designed to ensure timely responses, particularly for individuals with chronic illnesses.
EPS Facing the Highest Reopening Rates
Several EPS (Entidades Promotoras de Salud) are experiencing disproportionately high rates of claim reopenings. Nueva EPS, Compensar, and Emssanar are identified as leading the list, signaling a critical need to bolster their mechanisms for addressing and monitoring complaints to prevent recurring disagreements.
Claim Rates Vary Significantly Across Providers
An analysis of claim rates, excluding special and exceptional regimes, revealed an average of 202.11 claims per 10,000 affiliates as of June 2025. However, significant variations exist among providers. Comfenalco Valle recorded the highest rate at 298.75 claims per 10,000 affiliates, followed by Capital Salud (289.82), Famisanar (277.41), SOS (268.80), and Compensar (263.79).
In absolute terms, Nueva EPS registered 295,390 claims during the analyzed period, with 161,179 already closed. Famisanar managed 154,133 claims, closing 138,551, while Compensar reported 91,971 records, with 87,367 resolved. Mutual Be closed 46,671 of the 50,465 claims filed. A visual representation of these claim volumes by EPS would further illustrate the disparities.
Special and Exceptional Regimes Show Stronger Closure Rates
The special and exceptional regimes demonstrated a higher closure rate, with 93.7% of the 49,219 claims registered by July 30, 2025, successfully resolved. The teaching sector accumulated 23,470 complaints, resolving 22,737, while the National Police registered 16,388 complaints, closing 14,609.
Intervention Status Impacts Claim Performance
Claim rates also vary based on whether an EPS is under intervention. Among intervened entities, Sanitas (220.70) and Nueva EPS (209.23) stood out after SOS and Famisanar. In the group of EPS not under intervention, Total Health (249.63) and Sura (223.68) recorded the highest rates, while My Health (164.12) and Alianzalud (140.52) fell below the national average. Asmetsalud, among the intervened entities, had the lowest rate at 93.41.
Superintendent Calls for Effective Solutions
The Superintendent, Giovanni Rubiano García, emphasized the need for effective solutions to prevent the reopening of already closed cases. “Give effective solution to citizens’ claims, avoiding the reopening of already closed cases,” a senior official stated. He also highlighted the importance of improving access to medicines and healthcare, particularly within intervened EPS, and continuing efforts to resolve outstanding claims.
The National Superintendence of Health acknowledged the contrast between the progress in closing claims and the persistent issue of reopenings. Permanent monitoring days are proving crucial in expediting responses and prioritizing care for patients with chronic conditions. Despite these advancements, the reopening of cases remains a significant challenge for the Colombian healthcare system, demanding sustained attention and systemic improvements.
