March 09--The latest twist in the long-running war between Pittsburgh health care giants UPMC and Highmark Inc. has degenerated into obscure interpretations of complex reimbursement contracts.
Caught in the middle are a small number of Highmark members who the insurer says are being unfairly denied treatment by Western Pennsylvania's largest hospital network.
UPMC counters that Highmark, the state's largest health insurer, has misled its customers into believing they could continue going to UPMC hospitals even though they bought Community Blue health coverage -- which is discounted because it excludes UPMC.
Whether one or the other is correct, patients are drawing the short straw, the president of the Allegheny County Medical Society said.
"If you're in the business of medicine you should be held to a higher standard," said Amelia Pare, a private practice plastic surgeon from McMurray who became president of the 2,800-member society this year. "The most important entity is the patient and that's what is lost in all of this."
State regulators also are paying attention after patients and Highmark complained.
The state Insurance Department fielded a half-dozen calls from patients in the last week who were denied treatment at UPMC because they have Highmark's Community Blue health plan, spokeswoman Melissa Fox said. But the department is referring those calls to the state Health Department, which oversees hospitals and doctors, she said.
Health department officials are trying to resolve individual cases, spokeswoman Kait Gillis said.
"We will continue to vigilantly monitor the situation as we work towards a solution," she said.
And the state Attorney General is "aware of the situation in Pittsburgh with regard to Community Blue," spokesman Dennis Fisher said. He would neither confirm nor deny that the AG's office is investigating and declined to comment further.
Some facts are not in dispute. Community Blue began Jan. 1 and UPMC this month said it could no longer treat Highmark members who had chosen to enroll in the plan.
Its origins can be traced to another fight that only was resolved after the state's top lawmakers waded into the mess.
In May last year, Gov. Tom Corbett and several high-ranking state lawmakers negotiated a deal to extend the broad contractual relationship between Highmark and all UPMC facilities through the end of 2014.
Without a contract extension, Highmark members would have been out-of-network at UPMC starting in July this year. UPMC had refused to renew the contracts because Highmark was buying UPMC rival West Penn Allegheny Health System. It is part of a Highmark plan to convert itself into an integrated provider of medical services and health insurance -- competing directly with UPMC.
As part of the deal, UPMC and Highmark also signed a separate contract governing Community Blue, a group of health plans for individuals and businesses that can cost up to 25 percent less but make most UPMC's hospitals and doctors out-of-network.
Where the situation gets muddy is when a Community Blue member wants treatment at a UPMC facility that is considered out-of-network. Those facilities can't treat Community Blue patients nor can they ignore their insurance and accept cash, UPMC spokesman Paul Wood said.
"We believe it would be unethical and illegal to enter into a side negotiation with a subscriber to figure out how they can go around their insurance provider," he said.
Wood said UPMC can't bill the patients like it would a normal out-of-network patient because the contract forbids it.
But Kristin Ash, a Highmark spokeswoman, said the contract spells out how the out-of-network payments are to be handled. She said there "is no contractual or financial reason for denying access."
"UPMC is being paid the same for Highmark patients whether it's in network or out," Ash said. "The only difference is the patient pays more" if they have Community Blue insurance.
But Wood maintains that the Community Blue contract does not cover treatment of patients at UPMC facilities that are considered out-of-network.
"It's clear that Highmark has not adequately communicated to its subscribers" that they would lose access to UPMC with Community Blue, Wood said.
And the fight goes on, which local health care consultant Jan Jennings predicted will never end.
It's a bad omen for anyone in Western Pennsylvania who wants the two titans to extend their broad contracts beyond the end of 2014, said local health care consultant Jan Jennings.
"As long as I live there will be a battle between Highmark and UPMC," he said. "It will never end."
Alex Nixon is a staff writer for Trib Total Media.
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