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Federal agency checking whether Highmark has enough doctors in Medicare plan

The federal government is reviewing whether Highmark Inc. has enough doctors in its network for Medicare subscribers since the insurer cancelled contracts with 689 UPMC physicians last week.

UPMC has said Highmark’s decision would make the doctors out-of-network for the insurer’s Medicare Advantage subscribers.

The Centers for Medicare & Medicaid Services is not reviewing the validity of the cancellation — the crux of a disagreement between Highmark and UPMC. The agency is concerned about a growing trend by insurers to reduce the number of medical providers in their networks to lower costs.

“Medicare Advantage plans must have a network of providers that meets Medicare’s established adequacy standards and meets beneficiaries’ health care needs,” CMS said Tuesday in a written statement.

CMS officials could not be reached for comment on how many provider networks besides Highmark’s are being examined.

Highmark said it canceled the contracts because the doctors would be out of network starting Jan. 1 for individual and employer plans under terms of a consent agreement the insurer and hospital network negotiated with state officials this summer. The agreement spells out what access Highmark members will have to UPMC providers once broad network contracts expire at the end of this year.

Highmark has said the consent agreement allows its Medicare Advantage members to see all UPMC doctors at in-network prices. Nevertheless, the insurer said it offered Medicare-only contracts to the physicians to make clear that they are still in-network for seniors, but UPMC has refused to sign.

UPMC has said that the contract terminations were a violation of the consent agreement. It argued that Highmark’s Security Blue and Freedom Blue customers will have to pay costly out-of-network rates to be treated by those doctors whose contracts were canceled. The cancellations do not affect about 2,800 other UPMC physicians who are in Highmark’s network, depending on where they practice.

No timeline was given for when CMS will determine if the contract cancellations made Highmark’s Medicare network inadequate. If that determination is made, the agency said it may notify subscribers that they can change plans during a special enrollment period.

Highmark spokesman Aaron Billger said the state’s largest health insurer, which has about 145,000 Medicare Advantage subscribers in Western Pennsylvania, was unaware of the review.

“CMS has approved our new Community Blue Medicare HMO and we have more than 10,500 providers in our broad access plans like Security Blue HMO and Freedom Blue PPO,” he said. That number would include physicians employed by UPMC and other systems.

Alex Nixon is a staff writer for Trib Total Media. He can be reached at 412-320-7928 or [email protected].


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