UPMC threatens to block Medicare Advantage access for Highmark members

Pittsburgh-based UPMC and health insurer Highmark are continuing to battle, and UPMC has said it will cut off Medicare Advantage access for Highmark members unless certain conditions are met, according to a Pittsburgh Post-Gazette report.

UPMC warned that those with Highmark Medicare Advantage plans will be pushed out of the system's network Jan. 1, 2016, unless Highmark increases the rates it pays to UPMC for cancer care.

Medicare regulations allow health systems to bill insurers at hospital outpatient center rates for the same care provided in system-owned physicians' offices, a practice that sometimes leads to reimbursement being tripled. Highmark quit paying UPMC the higher rates for cancer care in April 2014, according to the report.

UPMC is also demanding that Highmark drop a lawsuit against the system over cancer care payments. Highmark filed a lawsuit against UPMC in 2014, alleging it had overpaid UPMC on chemotherapy fees since 2010.

Pennsylvania Gov. Tom Wolf said his office will pursue legal action against UPMC if that is what it takes to reverse the system's decision to block access to Highmark Medicare Advantage customers, as UPMC's decision is a "clear violation" of the consent decree that it previously entered into with Highmark.

Paul Wood, a UPMC spokesman, told the Pittsburgh Post-Gazette, "This is entirely Highmark's doing." He said it is up to the insurer to pay the amount it owes UPMC and to drop the lawsuit. Much of the amount UPMC claims it is owed by Highmark is tied up in Medicare patients, according to the report.

David Carter, a Highmark spokesman, told the Pittsburgh Post-Gazette that his company "applauds the state's action and the governor's [intention] to enforce the consent decree." Mr. Carter said, "It's sad, but true, that when you get past the misrepresentation and the accusations, UPMC's action is all about money."

More articles on the UPMC-Highmark battle:

Hospital-insurer disputes: Are things about to get ugly?
Latest development in Highmark, UPMC battle involves delayed payments
Attorney General launches UPMC-Highmark helpline for questions on split


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