Highmark members face a minefield for UPMC care



Anyone who is curious about what navigating the local health insurance-medical care scene will be like in coming months and years can stop by Lenzi’s Restaurant in Monongahela, Washington County, and speak to owner John Timko.

Last week, an office worker for Mr. Timko’s cardiologist — a UPMC physician he credits with saving his life after a heart attack nearly five years ago — informed him they were canceling his regular appointment, scheduled for Monday.

The reason: After watching his UPMC Health Plan premiums jump to what he considered an unaffordable $1,800 per month, Mr. Timko had switched to Highmark Community Blue insurance Jan. 1.

UPMC has refused to see Community Blue members since early 2013, even if they’re willing to pay cash, because the low-cost plan pays lower rates and excludes many of the UPMC facilities and physicians from its in-network directory.

It looked as though Mr. Timko unknowingly was caught in the middle and would lose his physician.

After an inquiry by the Pittsburgh Post-Gazette this week, though, UPMC has granted an exception for Mr. Timko so he can keep seeing his doctor.

UPMC spokesman Paul Wood also said, under continuity of care provision in the June 27 consent decree brokered by Gov. Tom Corbett and Attorney General Kathleen Kane, Mr. Timko will continue to see his UPMC physician on an in-network basis after the UPMC-Highmark contract ends Jan. 1.

But that’s not necessarily the case, Highmark spokesman Aaron Billger said Thursday, adding only that “we continue to work with state regulators to determine which provisions apply to Community Blue and which do not.”

While Mr. Timko’s situation appears to have a happy ending, at least for now, the ongoing Highmark-UPMC battle for many has generated a mix of confusing and sometimes conflicting information. Highmark is scheduled next week to submit a formal transition plan for when the two health care nonprofits separate Jan. 1 that should add clarity — but that doesn’t mean it will be clear for everyone.

“I feel that a lot of people are going to fall into this category,” Mr. Timko said. “You never understand what your health insurance is until you use it.”

Mr. Timko was aware the two health giants were fighting but said he did not realize the particular battle over Community Blue that put his physician-patient relationship in jeopardy. Once he learned the Highmark-UPMC contract went through 2014, he thought he could still see his UPMC cardiologist when he switched his insurance. “Highmark is Highmark to me,” he said.

Also, he had recently heard that the two sides had agreed that UPMC would continue to treat Highmark members with serious illnesses at in-network rates. “I consider my heart a serious condition,” said Mr. Timko, who turns 64 next week. He also has diabetes and is being treated for high blood pressure.

Now that UPMC has granted the exception, though, he will be able to see the doctor at Century Cardiac Care in Monongahela without interruption.

“He knows my case, he understands me and we’ve gone through a lot in the past five years,” said Mr. Timko. “I have a very good relationship with him and the office. I was shocked to be told, ‘We can’t see you anymore.’ ”

After 10 years with UPMC Health Plan, he said he would not have switched insurers in the first place, but the 32 percent yearly premium increases got to be too much.

Adding to his frustration, he said, was being an eyewitness to the onslaught of UPMC and Highmark ads over the past two years, ads that he figures were being paid for with his premium dollars.

“Every time I see a commercial, I want to throw something at the TV,” he said.

Steve Twedt: stwedt@post-gazette.com or 412-263-1963.


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