Health giants Highmark, UPMC swap mix-up blame

Highmark, UPMC pass buck to each other for out-of-network visit

Share with others:


Print Email Read Later

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

Join the conversation:

Commenting policy | How to report abuse
To report inappropriate comments, abuse and/or repeat offenders, please send an email to socialmedia@post-gazette.com and include a link to the article and a copy of the comment. Your report will be reviewed in a timely manner. Thank you.
Commenting policy | How to report abuse

Advertisement
Advertisement
Advertisement

You have 2 remaining free articles this month

Try unlimited digital access

If you are an existing subscriber,
link your account for free access. Start here

You’ve reached the limit of free articles this month.

To continue unlimited reading

If you are an existing subscriber,
link your account for free access. Start here