Health giants Highmark, UPMC swap mix-up blame

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

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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.

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