UPMC, Highmark clash over newly announced prepay rule for out-of-network patients

October 3, 2018

The UPMC sign sits atop the U.S. Steel Tower in downtown Pittsburgh.

UPMC warned Monday that, beginning in July, Highmark-insured Medicare Advantage members no longer will be able to receive non­emergency medical care from most UPMC providers unless patients pay their estimated bills in full before getting treated.

Patients on Highmark plans seeking to schedule a surgery next summer at most UPMC hospitals, for instance, will 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 going under the knife, 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.

The change is set to take effect June 30, when a state- brokered consent decree between the two Western Pennsylvania health care rivals expires and ends UPMC’s obligation to accept Highmark insurance plans.

But Highmark Health officials say the new prepay mandate caught them by surprise, sending executives scrambling to clarify the scope and impact of what Highmark spokesman Aaron Billger described as “an extremely unusual” move by rival UPMC.

The notion of patients -- even out-of-network ones -- having to pay their estimated bills in full prior to a doctor’s visit or surgery goes against the norms of other “providers across the nation, when our Medicare Advantage members travel and may see an out-of-network provider,” Billger said.

“Providers in other markets always bill us directly; they don’t put the senior in the middle,” Billger said. “We need to seek clarity on what UPMC actually means by this. ... Nationwide, we’ve never seen anything like it before.”

The pay-in-advance rule further clashed with reassurances by Highmark that members in two of its Medicare Advantage plans -- Freedom Blue and Security Blue -- may continue to see UPMC providers through the end of 2019 via a virtually “seamless” transition that keeps costs the same regardless of network.

This year, about 50,000 seniors living in Allegheny and Erie counties have Security Blue and Freedom Blue plans, and about 17,000 seniors in Westmoreland County have Medicare Advantage plans that provide access to UPMC. People with Highmark’s Community Blue plans, which don’t include UPMC, won’t see any changes.

On Monday morning, Dr. Steve Shapiro, chief medical and scientific officer at UPMC, sent UPMC physicians an internal memo describing the prepay requirement. It also stated that Highmark “has a strong financial incentive to ensure that your patients transfer their care away from you.”

“We sent this note around to our physicians because we didn’t want any of their patients to be surprised,” UPMC spokesman Paul Wood said.

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. Wood suggested that people choose non-Highmark plans to avoid dealing with the hassle.

This week, individuals across the region will receive mailers from UPMC asking them to consider whether they could lose access to UPMC doctors.

“If you choose to access nonemergency care from a UPMC provider that is out-of-network, you will be required to pay in advance,” the UPMC advertisement says. It states that consumers can maintain full UPMC in-network access through UPMC insurance or plans by Aetna, Coventry, Cigna and United Healthcare.

Wood said, after a patient pays in advance for an out-of-network service, “what -- and whether -- Highmark reimburses them will be strictly an issue between Highmark and the patient.”

Highmark officials urged members to call their offices to get further clarity.

The mixed messages from the health care giants coincided with Monday’s release of the 2019 rates nationwide for Medicare Advantage plans, which are private alternatives to traditional Medicare coverage available to people older than 65 or with disabilities.

Medicare Advantage plans have grown sharply in popularity in recent years, especially among the baby-boomer generation.

In Western Pennsylvania, most of the roughly 40 available Medicare Advantage plans will cost the same or slightly less in 2019 than they did this year, and more offerings will be available, federal data shows. Plans range from $0 per month for narrow-network plans to more generous benefits and premiums totaling about $300 for an individual.

Both Highmark and UPMC also offer HMO plans with $0 monthly premiums and 2019 plans that include enhanced benefits such as more coverage for dental visits, vision care, hearing aids and perks like membership in the SilverSneakers exercise classes program.

UPMC is offering seven plans in Western Pennsylvania in 2019 -- including a new $0 monthly premium plan specifically for people who live in Westmoreland County.

UPMC Health Plan excludes from its networks most hospitals that are part of Allegheny Health Network, which is owned by Highmark Health. The exceptions are Jefferson Hospital in the South Hills and St. Vincent Hospital in Erie.

Seniors also may elect to enroll in traditional Medicare rather than the Medicare Advantage plans. The traditional program includes all hospitals and doctors in the country who accept Medicare. Another option is choosing a Medigap supplemental plan, which covers many of the co-pays, deductibles and other costs of traditional Medicare. All hospitals and doctors who accept Medicare must accept Medigap.

Open enrollment for Medicare plans runs from Oct. 15 through Dec. 7. For more information and to view specific plan details, visit Medicare.gov.

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