Judge: UPMC-Highmark split set for June 30

Jun. 14--A Commonwealth Court judge on Friday ruled against Pennsylvania Attorney General Josh Shapiro's request to block the insurance network split of UPMC and Highmark at the end of this month.

Judge Robert E. Simpson determined that Shapiro's legal team "cannot state a cause of action" for changing the expiration date created in a 2014 state-brokered agreement signed by the pair of feuding, Pittsburgh-based nonprofit health care giants.

The ruling followed a two-day evidentiary hearing in Harrisburg focused on whether the court had the ability to change the agreement's June 30 end date in the name of public interest.

Shapiro said he had the right to do so as a watchdog over public charities and via a modification clause folded into the consent decree.

UPMC lauded the judge's decision for reinforcing its position that the 5-year-old agreement "should terminate, as intended and anticipated by all, on June 30, 2019."

"UPMC is grateful the Commonwealth Court expeditiously reached this decision," UPMC spokesman Paul Wood said in a statement. "We look forward to continuing to fulfill our long-standing charitable mission and serving the public with UPMC's world-class physicians and facilities."

Shapiro said that his broader fight against UPMC is far from over.

"Make no mistake -- our work here is not done," Shapiro said.

Gov. Tom Wolf spokesman J.J. Abbott said the Wolf administration is reviewing the ruling and "assessing the path forward in consultation with the Attorney General's Office."

June 30 split looms

Officials from Highmark -- which sides with Shapiro against its rival -- said that Friday's court outcome is just another hurdle to overcome in Shapiro's broader quest to force changes upon UPMC, including requiring it to contract with any interested insurer. Shapiro further has questioned UPMC's nonprofit status and whether it's violating public charities and consumer protection laws.

"This ruling is not a defeat in preserving health care choice for consumers, but rather just a temporary setback," Highmark spokesman Aaron Billger said.

In about two weeks, thousands of Highmark-insured patients will become out-of-network at most UPMC hospitals in Western Pennsylvania.

They will be subject to a controversial prepay-in-full rule should they seek non-emergency care from UPMC doctors.

Exceptions could include most Medicare Advantage members as well as anyone on any plan who seeks oncology treatment from doctors and facilities associated with Hillman Cancer Center. UPMC announced the relaxed prepayment policy for those types of patients last week.

But Highmark maintains that it has not received any formal contracts or commitments from UPMC in writing.

"To protect our health plan members and patients, we need to secure contract language and agreements so that UPMC's practices align with their verbal commitments," Billger said. "We look forward to working with the Attorney General and UPMC, if UPMC is willing to work in good faith."

Prepay rule to take effect July 1

UPMC maintains that it has no obligation to offer non-emergency treatment to Highmark patients after June 30. UPMC says that it is making an "accommodation" by allowing Medicare Advantage and Hillman Cancer Center patients to do so.

Highmark's commercial market patients not receiving oncology care at Hillman Cancer Center -- along with other out-of-network patients -- still will be subject to the controversial prepay rule as of July 1 at most UPMC hospitals and specialty centers -- including UPMC Magee-Womens Hospital, UPMC St. Margaret hospital in Pittsburgh and UPMC East hospital in Monroeville. Exceptions include UPMC Western Psychiatric Hospital, UPMC Children's Hospital of Pittsburgh and hospitals in rural areas.

The Attorney General's Office plans to announce its next legal steps next week.

"While we are disappointed in Judge Simpson's ruling, I won't quit on the people of Western Pennsylvania and we will continue to take steps to restore fairness to the health care system and give people access to the institutions their tax dollars built," Shapiro said.

Simpson noted in his order that an appeal to the state Supreme Court would be an option.

"An immediate appeal may materially advance the ultimate termination of the matter," Simpson wrote.

RELATED: UPMC preserves access to Hillman Cancer Center for all Highmark-insured patients

Natasha Lindstrom is a Tribune-Review staff writer. You can contact Natasha at 412-380-8514, [email protected] or via Twitter .

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