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Highmark, UPMC agree over in-network access to doctors and hospitals

Wes Venteicher
| Friday, Nov. 13, 2015, 12:02 a.m.

Rivals UPMC and Highmark Inc. announced an agreement Thursday regarding which Highmark members will retain in-network access to UPMC doctors and hospitals.

Under the agreement, effective Jan. 1, 2016, through June 30, 2019, UPMC doctors will determine whether their patients' care qualifies as a “continuing course of treatment” — and therefore will be billed at in-network rates.

The agreement, along with a ruling about cancer payments issued this week, should make buying insurance for 2016 easier than buying insurance for 2015, said James McTiernan, area vice president for consultant Arthur J. Gallagher & Co.

“The purchaser will have better clarification, a better knowledge base of exactly what they're purchasing,” McTiernan said.

The agreement resolves a bitter dispute that erupted with the expiration of a longstanding commercial contract between UPMC, the region's largest hospital system, and Highmark, the state's largest insurer. The contract, which ended Dec. 31, gave Highmark insurance customers in-network access to UPMC doctors and hospitals.

A state-brokered consent decree sought to smooth the transition and shield patients from the fallout, but the rivals clashed over its interpretation.

UPMC argued that Highmark patients should continue to be able to see their UPMC doctors and receive care at UPMC hospitals at in-network rates. Highmark, on the other hand, sought to reserve the lower rates for people with serious medical conditions.

According to the agreement, in-network access to Highmark members will be granted to people who were under treatment at UPMC in 2013, 2014 and 2015 with a “chronic or persistent medical condition.” Routine wellness or preventive care does not qualify for in-network rates.

Pregnant women receiving care at UPMC before Dec. 31 may continue to get in-network rates for maternity care, delivery and postpartum care, according to the agreement.

“It's an important day because this agreement brings clarity to our members and the community,” Highmark spokesman Aaron Billger said in a statement. “This agreement also is important for the next three and half years, as our relationship with UPMC comes to a close. In the days and weeks ahead, we will be working with our members and providers to understand the agreement.”

For the remainder of 2015, the sides will continue reviewing cases, Billger said.

“This confirms that decisions regarding continuity of care are to be made by the patient and his or her treating physician, subject to appeal by Highmark to the Pennsylvania Department of Health,” UPMC spokesman Paul Wood said in a statement. “As always, consumers who want to be assured of full and unfettered affordable in-network access to UPMC physicians and hospitals should choose an insurer other than Highmark, including UPMC Health Plan, Aetna, Cigna and United Healthcare. Consumers choosing to remain with Highmark for 2016 should consult with their physician to determine if they will be covered by this agreement.”

Thursday's announcement follows news earlier this week that Highmark will pay UPMC about $188 million for cancer patients received from April 2014 through October 2015. An arbitration panel ruled in favor of UPMC in a disagreement over how much the insurer owed the hospital system for oncology under commercial contracts.

A third disagreement regarding a broad set of rates between the two sides was concluded in October, according to court documents.

Both sides are waiting on a state Supreme Court decision on whether UPMC must continue providing in-network access to 182,000 seniors with Medicare Advantage plans from Highmark.

Wes Venteicher is a staff writer for Trib Total Media. He can be reached at 412-380-5676 or

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