Under the state-brokered transition agreement signed June 27, Highmark and UPMC officials must come to terms by today on rates that Highmark subscribers will pay for cancer treatment and emergency room care at UPMC facilities after the contract between the two Pittsburgh health giants expires Dec. 31.
Based on a flier that UPMC has circulated to employers and insurance brokers, though, it is difficult to imagine them agreeing on much of anything.
After a recent Highmark newspaper ad touted subscribers’ continued access to UPMC physicians and hospitals once the current contract ends, UPMC is questioning or refuting the claims point-by-point.
Cancer treatment? The June 29 Highmark ad in the Post-Gazette says the insurer’s members “will have in-network access to all UPMC services for oncology care, including the Hillman Cancer Center.” UPMC says that only happens “if the subscriber’s physician determines that the subscriber should be treated by a UPMC oncologist rather than, say, an AHN [Highmark Health’s Allegheny Health Network] oncologist.”
Emergency care? Highmark told members in the ad that they “will be covered at any UPMC emergency room at in-network rates.” Not so fast, counters UPMC. The patient’s in-network care lasts “only until stabilized for transfer to an in-network facility under protocols yet to be announced.”
There are other areas of disagreement, too. According to Highmark, members “in a continuing course of treatment with a UPMC provider” will be able to continue that in-network care. UPMC says that only continues “unless and until Highmark disputes the opinion of the treating physician.”
And the transitions plan’s “safety net,” allowing Highmark members to continue seeing their UPMC physician through 2015 if they can’t find another doctor, may not apply to as many people as it seems, according to UPMC.
“Highmark is analyzing claims data to match its subscribers with non-UPMC providers, limiting the number of subscribers who will be able to claim that they cannot find another doctor,” the flyer states.
UPMC has long maintained that it is not renewing its contract with Highmark in the belief that Highmark will be steering members to physicians and hospitals in the insurer’s own Allegheny Health Network.
The new flyer is in response to what UPMC spokesman Paul Wood called Highmark’s “misrepresentations and incompleteness of the information provided” in the ad.
He emphasized that patients’ only assurance of full, in-network access to UPMC care is by selecting health insurance through UPMC Health Plan or one of the national carriers that UPMC has contracted with: Aetna, Cigna, United Healthcare or Coventry.
Aaron Billger, spokesman for Highmark, declined to address the specifics of the flyer but said the Highmark ad was intended to show that “Highmark members will have access to AHN hospitals, community hospitals and many UPMC sites at in-network rates.”
“Moreover, they are guaranteed access to all hospital facilities at higher than in-network rates but still at capped numbers that will provide patient and member choice.”
As to today’s deadline on rates, Mr. Billger said only that “we are continuing to work on the agreement.”
Steve Twedt: firstname.lastname@example.org or 412-263-1963.