UPMC to drop prepay rule for seniors; prepay still to affect younger patients, Hillman Cancer Center

UPMC said Wednesday it will drop a controversial prepay rule aimed at Highmark-insured Medicare Advantage patients when the competing health giants split insurance networks.

The decision means that more than 100,000 senior citizens and people with disabilities enrolled in Highmark’s Freedom Blue and Security Blue Medicare Advantage plans will not have to worry about paying in full prior to receiving non-emergency care at UPMC hospitals.

For those patients, UPMC will bill Highmark and other out-of-network insurers directly for services rendered to their members and accept reimbursement at the federally set Medicare fee schedule amounts, eliminating the need for prepay, UPMC spokesman Paul Wood said Wednesday.

UPMC also committed to accepting direct payment from Highmark for emergency care claims at the same rate that UPMC Health Plan now pays Highmark’s Allegheny Health Network hospitals.

UPMC announced the relaxed prepay rule policy less than a week before Pennsylvania Attorney General Josh Shapiro’s legal team will make its case against UPMC in Commonwealth Court to prevent the UPMC-Highmark split from happening, or at least postpone it, in the name of public interest.

On Tuesday, a judge denied UPMC’s motion to block Highmark from arguing in support of Shapiro and against UPMC during the two-day trial next week.

UPMC attributed the policy reversal in regards to Medicare Advantage plans to “recent statements from Highmark indicating that it will pay UPMC directly and in full for many of these services and that it, like UPMC, wants to eliminate the need for ‘balance billing,’ ” Wood said.

Prepay not lifted for everyone

But the change will not lift the prepay rule for younger patients insured by Highmark either through their employer or via Highmark insurance purchased through the federal health exchange. Those Highmark customers still would have to pay in full prior to receiving non-emergency procedures at most UPMC hospitals.

UPMC blamed persisting billing disputes over how Highmark handles other types of claims for keeping the prepay policy on non-Medicare Highmark patients who seek nonemergency treatment from UPMC facilities and doctors.

Should younger, out-of-network patients want to schedule a surgery or treatment at most UPMC facilities — among them Hillman Cancer Center at UPMC Shadyside hospital, UPMC Magee-Womens hospital and UPMC St. Margaret hospital — they still must prepay, in full, before receiving any care, plus pay for any additional costs that arise during treatment.

Also subject to the prepay rule will be more than 25,000 members of Highmark’s Community Blue Medicare Advantage plans, cheaper alternatives that specifically exclude UPMC hospitals and doctors. Wood said that the prepay rule still will apply because “this plan explicitly has no out-of-network benefits applicable for UPMC care.”

“UPMC’s statements to the media about prepay for Community Blue members is inconsistent with what we are led to believe has been communicated to the state,” Highmark spokesman Aaron Billger told the Tribune-Review on Wednesday.

UPMC says the reason it chose to make those types of patients prepay is that Highmark reimburses those patients differently.

For members who obtain insurance from their employers or buy it on the federal health exchange, Highmark pays an out-of-network allowance that the patient then is supposed to pay to UPMC. UPMC does not want to have to chase payments.

Wood said UPMC might consider relaxing the prepay rule for all out-of-network patients if Highmark agrees to pay UPMC directly for their commercial claims akin to the way Medicare Advantage claims get paid.

“We are awaiting Highmark’s response,” Wood said.

Highmark contends that it has done so all along for Medicare Advantage patients and never intended to stop.

“We have always been focused on doing what’s right for our customers and patients,” Billger said. “We are glad UPMC is now in agreement with us. We have long said that UPMC’s actions were unnecessary and unprecedented. It’s a shame they promoted this in the first place.”

UPMC warned that it could reinstate the prepay rule for Medicare Advantage patients if it runs into billing problems with Highmark.

“Should Highmark fail to pay the billed amounts directly to UPMC,” Wood said, “UPMC will have to reconsider its decisions regarding prepayment and balance billing.”

RELATED: These UPMC hospitals won’t accept Highmark patients as in-network in July