Health insurance expert calls UPMC prepay mandate ‘harsh’

Oct. 03--Highmark officials are asking UPMC to reconsider its plan to require Highmark-

insured Medicare Advantage

patients to prepay their non­emergency medical bills in full if they want to continue using UPMC facilities and doctors next summer.

The prepay requirement -- announced this week along with the release of 2019 Medicare plan rates nationwide -- is set to take effect June 30, when a state-brokered consent decree obligating UPMC to treat Highmark patients expires.

"We are reaching out to UPMC to clarify if they will ask our members to pay the full amount for services, and why they wouldn't continue to bill Highmark like they always have," Highmark spokesman Aaron Billger said Tuesday. "Providers across the nation have historically billed us directly for Medicare Advantage out-of-network care."

The burden that the prepay rule would place on patients clashes with assurances from Highmark officials that two of their Medicare Advantage plans -- Freedom Blue and Security Blue -- would include out-of-network coverage such as UPMC, even beyond the consent decree. Highmark had pledged to pick up the extra costs so members in those plans would pay the same rates for in- and out-of-network services -- at least through the end of 2019.

Billger called the notion of requiring patients to work out the reimbursements on their own prior to getting treated "highly unusual." He pointed out that patients in Erie frequent the Cleveland Clinic, for instance, and the Ohio provider then bills the patient via Highmark.

Not only does the prepay requirement seem to be "unusual, it sounds harsh," said Steve Foreman, professor of health care administration at Robert Morris University.

Foreman, who has studied the health insurance industry nationally for 25 years, said he never has seen any insurers force out-of-network patients to pay their entire bills in full before receiving a medical service.

Effectively, the rule means that Highmark-insured Medicare Advantage patients without deep enough pockets to front the costs of scheduled procedures and specialty visits will be forced to avoid most UPMC facilities, Foreman said.

On average, Medicare spends $16,000 to more than $30,000 per surgical procedure.

Under the prepay change UPMC announced to its physicians and the public Monday, beginning on July 1, patients on Highmark plans seeking to schedule a surgery at most UPMC hospitals, for instance, would have to request the help of UPMC's estimate service, make an appointment via a centralized scheduling system and pay the balance of the estimate in full prior to the surgery, according to an internal memo sent to UPMC physicians in greater Pittsburgh and Erie.

UPMC says it will not accept partial payments nor arrangements such as payment plans. Patients also may be billed for additional costs should other medical needs arise during treatment.

UPMC officials described the prepay option as making an accommodation for Highmark members who choose to schedule visits at UPMC doctors once the decree ends. UPMC spokesman Paul Wood suggested that people choose non-Highmark plans to avoid dealing with the hassle. Members can retain full UPMC in-network access through UPMC insurance or plans by Aetna, CoventryCigna and United Healthcare.

In the meantime, Highmark encouraged members to call their offices or visit their insurance plan retail stores for more information.

They also offered another potential workaround for members concerned about losing access to their UPMC doctors and facilities this summer: Consider buying a supplemental insurance policy option known as a Medigap plan.

Bill McKendree, coordinator for the Allegheny County

APPRISE program, which helps seniors with enrollment for the Department of Aging, said that for $150 to $180 a month, seniors can get Medigap coverage that covers the co-pays, deductibles and other costs of traditional Medicare -- and would allow patients to see any doctor anywhere.

"Medigap plans have no network and Medigap members can seek care from any health care provider that accepts Medicare," Billger said. "For any Medicare Advantage member who has concerns about their coverage, they should contact us to see if a Medigap plan is right for them."

The catch for some people is that there is a limited window on when they can buy a Medigap policy, typically within six months of receiving Medicare coverage.

McKendree said the volume of calls to his insurance help hotline for seniors has risen sharply in recent months -- up to about 50 to 60 calls per day since August.

Roughly half to 60 percent of callers have been Western Pennsylvanians concerned about the impact of the end of the Highmark/UPMC consent decree, McKendree said.

"You've got two health care giants facing off. ... This one is a political hot potato," said Foreman, with elderly patients potentially the ones left in the lurch amid the confusion.

The state brokered the consent decree between Highmark and UPMC in 2014 to govern relations between them until 2019. The two nonprofits had been unable to resolve contract disputes on their own that arose after Highmark Inc. announced it was buying the former West Penn Allegheny Health System to form the basis of Allegheny Health Network. UPMC said it wouldn't contract with an organization owning competing hospitals.

Natasha Lindstrom is a Tribune-Review staff writer. Reach her at 412-380-8514, [email protected] or via Twitter @NewsNatasha.

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