Highmark, UPMC square off over Community Blue coverage
By Alex Nixon
Published: Saturday, March 9, 2013, 12:01 a.m.
The latest twist in the long-running war between Pittsburgh health care giants UPMC and Highmark Inc. has degenerated into obscure interpretations of complex reimbursement contracts.
Caught in the middle are a small number of Highmark members who the insurer says are being unfairly denied treatment by Western Pennsylvania's largest hospital network.
UPMC counters that Highmark, the state's largest health insurer, has misled its customers into believing they could continue going to UPMC hospitals even though they bought Community Blue health coverage — which is discounted because it excludes UPMC.
Whether one or the other is correct, patients are drawing the short straw, the president of the Allegheny County Medical Society said.
“If you're in the business of medicine you should be held to a higher standard,” said Amelia Pare, a private practice plastic surgeon from McMurray who became president of the 2,800-member society this year. “The most important entity is the patient and that's what is lost in all of this.”
State regulators also are paying attention after patients and Highmark complained.
The state Insurance Department fielded a half-dozen calls from patients in the last week who were denied treatment at UPMC because they have Highmark's Community Blue health plan, spokeswoman Melissa Fox said. But the department is referring those calls to the state Health Department, which oversees hospitals and doctors, she said.
Health department officials are trying to resolve individual cases, spokeswoman Kait Gillis said.
“We will continue to vigilantly monitor the situation as we work towards a solution,” she said.
And the state Attorney General is “aware of the situation in Pittsburgh with regard to Community Blue,” spokesman Dennis Fisher said. He would neither confirm nor deny that the AG's office is investigating and declined to comment further.
Some facts are not in dispute. Community Blue began Jan. 1 and UPMC this month said it could no longer treat Highmark members who had chosen to enroll in the plan.
Its origins can be traced to another fight that only was resolved after the state's top lawmakers waded into the mess.
In May last year, Gov. Tom Corbett and several high-ranking state lawmakers negotiated a deal to extend the broad contractual relationship between Highmark and all UPMC facilities through the end of 2014.
Without a contract extension, Highmark members would have been out-of-network at UPMC starting in July this year. UPMC had refused to renew the contracts because Highmark was buying UPMC rival West Penn Allegheny Health System. It is part of a Highmark plan to convert itself into an integrated provider of medical services and health insurance — competing directly with UPMC.
As part of the deal, UPMC and Highmark also signed a separate contract governing Community Blue, a group of health plans for individuals and businesses that can cost up to 25 percent less but make most UPMC's hospitals and doctors out-of-network.
Where the situation gets muddy is when a Community Blue member wants treatment at a UPMC facility that is considered out-of-network. Those facilities can't treat Community Blue patients nor can they ignore their insurance and accept cash, UPMC spokesman Paul Wood said.
“We believe it would be unethical and illegal to enter into a side negotiation with a subscriber to figure out how they can go around their insurance provider,” he said.
Wood said UPMC can't bill the patients like it would a normal out-of-network patient because the contract forbids it.
But Kristin Ash, a Highmark spokeswoman, said the contract spells out how the out-of-network payments are to be handled. She said there “is no contractual or financial reason for denying access.”
“UPMC is being paid the same for Highmark patients whether it's in network or out,” Ash said. “The only difference is the patient pays more” if they have Community Blue insurance.
But Wood maintains that the Community Blue contract does not cover treatment of patients at UPMC facilities that are considered out-of-network.
“It's clear that Highmark has not adequately communicated to its subscribers” that they would lose access to UPMC with Community Blue, Wood said.
And the fight goes on, which local health care consultant Jan Jennings predicted will never end.
It's a bad omen for anyone in Western Pennsylvania who wants the two titans to extend their broad contracts beyond the end of 2014, said local health care consultant Jan Jennings.
“As long as I live there will be a battle between Highmark and UPMC,” he said. “It will never end.”
Alex Nixon is a staff writer for Trib Total Media.
Show commenting policy
TribLive commenting policy
You are solely responsible for your comments and by using TribLive.com you agree to our Terms of Service.
We moderate comments. Our goal is to provide substantive commentary for a general readership. By screening submissions, we provide a space where readers can share intelligent and informed commentary that enhances the quality of our news and information.
While most comments will be posted if they are on-topic and not abusive, moderating decisions are subjective. We will make them as carefully and consistently as we can. Because of the volume of reader comments, we cannot review individual moderation decisions with readers.
We value thoughtful comments representing a range of views that make their point quickly and politely. We make an effort to protect discussions from repeated comments either by the same reader or different readers.
We follow the same standards for taste as the daily newspaper. A few things we won't tolerate: personal attacks, obscenity, vulgarity, profanity (including expletives and letters followed by dashes), commercial promotion, impersonations, incoherence, proselytizing and SHOUTING. Don't include URLs to Web sites.
We do not edit comments. They are either approved or deleted. We reserve the right to edit a comment that is quoted or excerpted in an article. In this case, we may fix spelling and punctuation.
We welcome strong opinions and criticism of our work, but we don't want comments to become bogged down with discussions of our policies and we will moderate accordingly.
We appreciate it when readers and people quoted in articles or blog posts point out errors of fact or emphasis and will investigate all assertions. But these suggestions should be sent via e-mail. To avoid distracting other readers, we won't publish comments that suggest a correction. Instead, corrections will be made in a blog post or in an article.
- Obama administration asking insurers to be flexible on health coverage
- ProStart primes student chefs for best kitchen jobs
- PNC plans to do away with tellers
- Senate Dems to push Obama nominees
- Early data reveal downward shift in holiday spending
- Washington County gas drilling spill cited in lawsuit not reported to state
- Cars, trucks get record gas mileage
- Some bargains improve once tree comes down
- Merrill to pay $131.8M to settle SEC charges
- Health-insurance mandate poses potential hitch for volunteer fire companies
- Economic recovery hinges on feds, experts say