Ritter Insurance Marketing, Craig Ritter

Highmark and UPMC in Disagreement Once Again

If you thought Highmark and UPMC’s embattled relationship was finally set straight by a state-brokered consent decree, you may have been too optimistic.

The five-year decree permitting Highmark members in-network access to UPMC physicians expires June 30, 2019. As usual, the two sides are in disagreement once again – this time over interpretation of what that date means.

UPMC’s Side

The massive health care provider plans to end in-network access to all Highmark members immediately after the consent decree expires, leaving Highmark members without in-network access to UPMC for six months of the year.

Highmark’s Side

The insurer argues that since Medicare contracts operate for a calendar year that begins January 1, in-network access cannot be rescinded before December 31, 2019.

The Rebuttal

Surely UPMC considered Highmark’s position. UPMC spokesman Paul Wood told the Pittsburgh Post-Gazette that Medicare’s run-out provision allows the company to terminate the Highmark contract at the end of 2018 and still provide in-network access for exactly six months. UPMC believes this would satisfy both the Medicare contract and consent decree obligations.

Highmark claims that terminating the Medicare contract prior to June 30, 2019, would violate the consent decree.

What’s Next?

The Post-Gazette reports that CMS, the Pennsylvania Insurance Department, and the state attorney general’s office are all remaining mostly neutral in the case.

When all is said and done, it’s very possible the two entities attempt to settle the matter in a familiar battleground – court.

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