Health care impasse muddled by physician fees

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For about 90 minutes Wednesday afternoon, it appeared that the Pennsylvania Department of Insurance had made a crucial decision in the ongoing contract dispute between Highmark and the University of Pittsburgh Medical Center.

On its website, on a page dedicated to answering frequently asked questions about the dispute, the site stated: "Once the contract expires, UPMC providers will be considered out-of-network."

After queries from the Post-Gazette, though, the department quickly changed the wording to say UPMC providers "may be considered out-of-network."

Insurance department spokeswoman Melissa Fox said it is still awaiting information from the two parties that will clarify whether UPMC physicians will be in-network for Highmark members during a one-year run-out period to June 30, 2013.

The issue has been a major point of contention between health system UPMC and insurer Highmark since negotiations to renew their 10-year contract broke down earlier this year.

Under the terms of the current contract, UPMC hospitals will be considered in-network for Highmark members with private insurance during a one-year run-out period after the contract ends, meaning Highmark members will pay in-network hospital rates until June 30, 2013.

Medicare recipients are not affected.

Highmark officials contend those hospital services also will include physician services, but their UPMC counterparts disagree, saying in-network access to UPMC physicians would end June 30, 2012.

UPMC spokesman Paul Wood said Wednesday that physician services typically comprise 40 to 60 percent of the bill for in-patient hospitalization, and that Highmark members could enjoy in-network rates for the hospital services, but face out-of-network charges for their physician services after June 30. How much of those extra charges will fall to the patient "is up to Highmark," he said.

Highmark spokesman Michael Weinstein reiterated Wednesday that Highmark believes the commercial hospital contracts include physician services, and that both will be available to Highmark members at in-network rates through June 30, 2013.

"If UPMC terminates the physician agreements, Highmark intends to continue to pay UPMC doctors at the in-network rate through June 30, 2013," he said.

The region's largest health system and largest insurer have been at loggerheads since Highmark let it be known that it intended to acquire the financially ailing West Penn Allegheny Health System.

UPMC officials have said they would not sign a new contract with an insurer who owns a competing provider network. It also signed expanded contracts with insurers Aetna, Cigna, United Healthcare and HealthAmerica.

Highmark officials have continued to say they are willing to resume negotiations with UPMC.

Insurance department officials have stated that they cannot force the two parties into a contract but Insurance Commissioner Michael F. Consedine does have the authority to suspend the termination of the contract for six months. Under Act 94, according to the department's website, additional periods of negotiation would extend the contract "until at least the end of April in 2013" before it is terminated.

On its website, the insurance department urged those with Highmark insurance to, "Review your benefits and/or contact your insurance company to determine if your policy has out-of-network benefits. You can expect to pay more if you choose to see these same providers. You may also contact your insurance company about selecting a new in-network provider."


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


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