Judge orders Highmark, UPMC lawyers to hash out consent decree

May 27--HARRISBURG -- Highmark Health Plan President Deborah Rice-Johnson on Wednesday denied a UPMC claim that the insurer owes the hospital system $100 million for oncology drugs and services.

She said UPMC inflates prices for certain services based on where patients receive the care.

Rice-Johnson took the witness stand in a Commonwealth Court hearing to resolve a complaint by state attorneys who accused the health care giants of breaking a consent decree state officials brokered in June.

Rice-Johnson denied an accusation that Highmark increased its rates for Medicare Advantage coverage since the consent decree took effect. She faced questioning from Stephen Cozen, a Philadelphia lawyer representing UPMC.

President Judge Dan Pellegrini, a former Pittsburgh city solicitor, told lawyers they will continue the hearing into the evening if needed.

UPMC put vulnerable populations at risk when it announced last month that it would not continue in-network access for Highmark's Medicare Advantage customers, including about 181,000 senior citizens, said James Donahue, executive deputy attorney general.

The problem stemmed from the companies "not talking directly to one another" as the consent decree was negotiated, Donahue told the judge. He said UPMC "created the problem by not talking to Highmark."

UPMC attorney Paul Pohl argued that the health care giant should not be held in civil contempt. Such a violation requires a decree that isn't ambiguous, he said.

"There is no evidence of wrongful intent," Pohl said. "Where's the specific language that leaves no doubt or uncertainity?"

UPMC argued that the consent decree, brokered in June to help patients navigate the dissolving relationship between the Downtown-based companies, gave the hospital system authority to withdraw if Highmark took the position it could raise rates unilaterally, Pohl said.

UPMC has cited about $143 million in unpaid bills that it says Highmark owes for cancer care. Highmark has alleged overbilling by UPMC.

Gov. Tom Wolf and Attorney General Kathleen Kane partnered last month in a joint motion aimed at both Downtown-based companies. Kane and the administration allege, in part, that UPMC's plan to end its Medicare Advantage arrangement with Highmark would break the decree.

Two witnesses took the stand before a mid-day break: Darlene Sampson, a Department of Aging official overseeing education efforts for seniors on Medicaid programs, and Barbara Gray, a Highmark senior vice president overseeing senior markets. Rice-Johnson was called to the stand in the afternoon.

Companies in the region providing Medicaid Advantage with in-network assets to UPMC facilities, such as Aetna, would probably raise premiums, said Gray, based on her business experience.

UPMC argues that Medicare Advantage customers can retain in-network access to the dominant hospital system by switching insurers during open enrollment that starts in October. The health system plans to terminate its Medicare Advantage arrangement with Highmark at the end of December.

The Wolf administration maintains that would violate a provision in the consent decree that's meant to protect senior citizens and children.

A longtime commercial contract that had allowed many Highmark customers in-network access to UPMC expired Dec. 31.

Brad Bumsted is Trib Total Media's state Capitol reporter. Reach him at 717-787-1405 or [email protected]. Staff writer Adam Smeltz contributed.

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