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Attorney General Shapiro expected to make announcement about UPMC-Highmark Medicare dispute

November 15, 2018

Pennsylvania Attorney General Josh Shapiro said he intends to make an announcement in coming weeks regarding his concerns over how UPMC and Highmark’s battle for health care marketplace domination is impacting and confusing patients, particularly seniors.

“We’re paying very close attention to the conduct of both Highmark and UPMC,” Shapiro told the Tribune-Review during a stop in Pittsburgh on Thursday.

“A number of things that they are doing is causing us great concern, and I know causing real confusion in the marketplace, especially for seniors,” Shapiro said, “and we will have more to say on that in coming weeks.”

Shapiro declined to elaborate on any potential formal intervention or steps being mulled by his office. He would not say whether his office has been in contact with the federal Centers for Medicaid and Medicare Services, which regulates the privately offered Medicare Advantage plans at the center of the latest chapter in UPMC and Highmark’s years-long rivalry.

A 2014 state-brokered consent decree between UPMC and Highmark intended to ease the transition of their insurance network split for consumers is set to expire at the end of June.

Beginning July 1, Highmark-insured Medicare Advantage patients no longer will be able to receive nonemergency treatment from most UPMC doctors and hospitals unless they obtain a cost estimate, schedule an appointment using a centralized system and prepay in full in advance. UPMC will not accept partial payments nor arrangement plans and will bill patients directly for any additional costs that arise during treatment.

The controversial prepay rule announced by UPMC on Oct. 1 clashed with reassurances made the same day by Highmark Health officials that under two of its Medicare Advantage insurance plans -- Freedom Blue and Security Blue -- members could continue seeing out-of-network doctors at the likes of UPMC facilities for the same price and billing method, at least through the end of 2019.

“At Highmark, we are focused on making health care accessible for seniors across the community,” Highmark spokesman Aaron Billger said Thursday by email. “That’s why this year’s Highmark Medicare Advantage products have expanded out-of-network benefit options. We have a legacy of being a trusted resource to seniors and are working to bring clarity to the issues.”

UPMC spokesman Paul Wood declined to comment on Shapiro’s remarks. He has previously said that to avoid the prepay hassle, anyone with an interest in using UPMC doctors and hospitals should choose an alternative, such as Aetna, Coventry, Cigna or UnitedHealth.

Though some industry experts called UPMC’s prepay rule “harsh” and highly unusual, others said they weren’t surprised by the move given the rivalry, and that the change appears to be allowable under federal rules governing the plans.

Shapiro’s remarks come as the $6 billion nonprofit health systems -- which each control insurer as well as provider arms -- continue to invest billions of dollars into new facilities and move on aggressive expansion plans across Pennsylvania and into neighboring states.

Other topics covered during visit

During his visit to Pittsburgh, Shapiro provided a few updates on his office’s ongoing investigation into child sex abuse by clergy and alleged cover-ups by leaders in the Catholic Church, including in the Western Pennsylvania dioceses of Pittsburgh and Greensburg.

The state Attorney General’s hot line for clergy child sex abuse victims (888-538-8541) has received 1,311 calls since the grand jury’s scathing report became public 10 weeks ago. The report accused 300 “predator” priests of child sex abuse across six Pennsylvania dioceses.

“That is unprecedented in terms of the call volume that we have received,” Shapiro said. “There are a number of calls that are very interesting to us that we are following through on, either through our office or through some other law enforcement agency.

“We have learned new information as a result of these calls,” added Shapiro, “and I want to encourage people to continue to call.”

Shapiro’s primary reason for visiting Pittsburgh was to join Mayor Bill Peduto, Allegheny County Executive Rich Fitzgerald and other local dignitaries in denouncing the Trump administration’s plan to roll back anti-pollution and fuel-efficiency standards for cars.

Trump officials have said the Obama-era standards -- intended to improve air quality and agreed upon by a bipartisan group of lawmakers as well as auto industry leaders -- could lead to more auto fatalities by promoting lighter cars and are overly burdensome on automakers, conclusions that clash with the Obama administration’s analyses.

Trump’s proposal also would prevent states from setting more stringent requirements such as those in California, a change that Shapiro argues would violate states’ rights.

Shapiro is joining 19 attorneys general around the country in submitting comments in opposition to the proposed rule.

“This is about our pocket books, this is about our environment, this is about public health and this is about rule of law,” Shapiro said.

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