Clarification sought from governor on Highmark-UPMC plan

The minority chairman of the House Insurance Committee has asked Gov. Tom Corbett, Attorney General Kathleen Kane and other officials to clarify key points of the June 27 Highmark-UPMC post-contract transition plan after a Pittsburgh Post-Gazette story showed that Highmark and UPMC have quite different interpretations.

Settling those disagreements could impact access and rates for Highmark members receiving a range of UPMC services, including cancer care and emergency room treatment.

State Rep. Tony DeLuca, D-Penn Hills, wrote to the transition plan parties that “specialty care, emergency care and continuity of care issues are not only far from resolved, but demand the attention of the parties who were at the table in finalizing the consent decree, and those who will make sure the consent decree is carried out.”

The agreement reached last month was meant to act as a “framework” for Highmark as it prepares a formal transition plan due to the Pennsylvania Insurance Department by July 31.

But the two consent decrees required the sides to agree on cancer treatment, emergency care and rates at outlying hospitals by July 15. That deadline was not met, so under the provisions of the transition plan, the rates now revert to “the last mutually agreed upon rates” through 2015 or until an agreement is reached.

UPMC has said it will not renew its in-network contract with Highmark now that the insurer has entered the provider market by setting up its own Allegheny Health Network.

Mr. DeLuca’s letter sets out, and asks for clarification, on a number of different scenarios including:

• While the transition plan gives Highmark members in-network access to care in UPMC emergency departments, UPMC says that only lasts until the patient is stabilized. So, Mr. DeLuca asked, once they are stable, “who will decide if that individual can stay in a UPMC facility with a UPMC physician or must be transported to an AHN facility? Is there any recourse and can an appeal be filed?”

• Who will decide if a Highmark member can continue receiving cancer treatment at UPMC? The agreement says it will be up to the patient’s physician whether they should be treated by a UPMC oncologist. But if the patient wants to be treated at UPMC and their AHN physician does not agree, “Is there any recourse and can an appeal be filed?” Mr. DeLuca asked.

• He also inquired about whether Highmark members currently being treated by a UPMC physician for a chronic condition can continue seeing that physician. The agreement says that is up to the treating physician in consultation with the patient.

“I want to make sure we have them on the record and that is why we asked these questions,” said Mr. DeLuca, who earlier this year introduced a bill that would give the state insurance commissioner more latitude to force the two sides to negotiate a new contract.

Spokespeople for UPMC and Highmark said late Wednesday that discussions on rates for some specialty services are continuing.

Steve Twedt: or 412-263-1963.

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