Monongahela restaurant owner John Timko thought he was back on course Thursday when UPMC granted him an exception to see his UPMC cardiologist even though he had Highmark Community Blue insurance.
That feeling of relief lasted less than 24 hours.
Mr. Timko said Friday that when he tried to schedule the appointment, the cardiologist’s office said they would be happy to see him “but I would be responsible to pay any additional fees,” Mr. Timko reported.
What’s worse, he added, they could not tell him how much those fees might be.
“I don’t want to get in there and find out it’s out-of-network and have it cost me three, four, five thousand dollars out of pocket. How do I know what I’m getting in?” he asked.
In fact, the visit will be considered out-of-network, said Highmark spokesman Aaron Billger, which could cost thousands of dollars. But on Friday Mr. Billger and UPMC spokesman Paul Wood each said the other organization would have to collect the difference between what Highmark pays and the final charges.
“This is Highmark’s fault — they misled this guy about the Yugo he was buying when he thought he was getting a BMW,” said Mr. Wood, adding that UPMC would bill Highmark, not Mr. Timko, for any remaining balance. “Whether Highmark can impose additional charges on Mr. Timko for his care at UPMC will continue to be controlled by the terms of his Highmark plan.”
Mr. Billger, on the other hand, said that while Mr. Timko would be responsible for the difference, “it’s up to UPMC whether or not they want to balance bill the charges.”
Mr. Timko, who had a heart attack about five years ago, was the subject of a Post-Gazette story Friday about how he switched from UPMC Health Plan to Highmark’s low-cost Community Blue plan on Jan. 1 after UPMC Health Plan had raised his monthly premium to $1,800 monthly.
What he didn’t realize was that UPMC has been refusing to see Community Blue subscribers because of its low reimbursement and its exclusion of many UPMC facilities and physicians.
Mr. Timko said his in-network deductible is $1,200, some of which he already paid after he went to the hospital in February with chest discomfort. But out-of-network, that deductible is $2,400 and he is responsible for half the remaining balance up to $7,400.
Faced with the possibility of a huge bill, Mr. Timko said he is still deciding whether to go to his 9 a.m. appointment Monday.
“I may go out of stubbornness, just to see where this falls.”
There is one silver lining: Mr. Timko turns 65 in a year, making him eligible for Medicare, which UPMC continues to accept.
For now, though, he said, “I’m at the point where I don’t believe anything anyone tells me, whether it’s UPMC or Highmark.”
Steve Twedt: email@example.com or 412-263-1963.