State jumps in UPMC-Highmark dispute, pushes binding arbitration

April 27--Gov. Tom Wolf and Attorney General Kathleen Kane are trying to force rivals Highmark Inc. and UPMC into binding arbitration to solve several disputes, including whether Highmark's Medicare Advantage customers can retain in-network access to UPMC in 2016.

Kane's office on Monday filed a Commonwealth Court motion seeking the arbitration and compliance with a consent decree that the Downtown-based companies signed in June. Each side has accused the other of violating the state-negotiated agreement, which was supposed to make it easier for Western Pennsylvanians to navigate the dissolving relationship between the groups.

"She's concerned about the effect that the continuing turmoil has on consumers -- and particularly older people who use the services," Kane spokesman Chuck Ardo said. "Things can become very confusing very quickly, and her interest is ensuring that people know what services are available and that those services are actually available."

The state insurance and health departments under Wolf joined the 17-page motion.

Highmark, the dominant health insurer in Pennsylvania, welcomed "the state's action to enforce the consent decree" but would decline additional comment before reviewing the motion, spokesman Aaron Billger said.

At UPMC, the largest hospital system in the region, spokesman Paul Wood said binding arbitration under these circumstances would fall outside the consent decre's parameters. He had yet to review the motion but said there is no "substantive or legal basis" to argue UPMC broke the decree.

"It just doesn't hold water," he said.

A long-standing commercial contract that had allowed Highmark customers in-network coverage at UPMC expired Dec. 31. Among other provisions, the consent decree lets some Highmark subscribers keep seeing UPMC doctors for ongoing care of specific medical conditions, such as pregnancy.

But the companies have clashed over interpretations of the agreement. In one instance, they fought in January over dozens of claims for children undergoing care at UPMC.

More recently, UPMC confirmed in April that it plans to sever in-network access at the end of 2015 for Medicare Advantage customers enrolled through Highmark. UPMC has said it has no choice because Highmark owes about $143 million for cancer care that UPMC provided to Highmark customers since February 2014.

The move means as many as 182,000 seniors in Western Pennsylvania would have to switch insurers later this year or lose in-network UPMC access in 2016. Kane's office, in the motion Monday, called the UPMC decision a violation of the consent decree.

Highmark has accused UPMC of misrepresentations and charging "grossly inflated prices for cancer drugs," a claim detailed in a pending lawsuit in Allegheny County Court. UPMC denies the allegations.

In a statement Monday, Wolf said he would not "allow our most vulnerable citizens, especially seniors, to be used as pawns in the dispute between UPMC and Highmark."

"UPMC's decision to cancel Medicare Advantage for over 180,000 seniors was the final straw after my administration's repeated attempts to resolve differences in good faith," he said.

The motion lays out several other areas where Highmark and UPMC remain at odds, including in-network rates and patient transfer protocols for emergency rooms and trauma services, reimbursement rates for select hospitals and processing for disputed claims.

___

(c)2015 The Pittsburgh Tribune-Review (Greensburg, Pa.)

Visit The Pittsburgh Tribune-Review (Greensburg, Pa.) at www.triblive.com

Distributed by Tribune Content Agency, LLC.