Highmark Inc. is delaying payment to UPMC on thousands of medical claims for the insurer's subscribers because of a dispute over whether the treatments qualify as in-network care.
The state's largest health insurer said it has asked the state to determine whether the claims satisfied language in a consent decree that was intended to settle confusion over when Highmark members can be treated at UPMC at less-costly in-network rates.
Highmark has held up some claims since Jan. 1, when a broad reimbursement contract with the biggest hospital system in Western Pennsylvania expired. UPMC said Highmark initially disputed 21,700 claims. Highmark said 14,396 have yet to be resolved.
“Essentially, they're saying (the claims) may not qualify as in-network,” UPMC spokesman Paul Wood said.
The determination is important because any claims that are considered out-of-network would result in higher charges billed directly to the patients. The consent decree caps the patient's bill at 60 percent of the total charge.
More than 723,000 claims have been paid since the beginning of the year, Highmark spokeswoman Lynn Seay said. The insurer has asked state regulators to provide a more detailed definition of when its members can be treated at UPMC at in-network rates, she added.
The two organizations have been fighting over the consent agreement that was brokered by former Gov. Tom Corbett's administration and Attorney General Kathleen Kane last year. The agreement governs their post-contract relationship and allows Highmark subscribers to continue receiving care at in-network rates from UPMC physicians if treatment started prior to Jan. 1.
Highmark has argued for a narrow interpretation of the provision, which would limit its members from going to UPMC. UPMC has advocated a broad reading, which would help keep its hospitals and doctor offices full.
Gov. Tom Wolf's administration said this month that it is up to Highmark-insured patients, in consultation with their doctors, whether they will continue care at UPMC. The statement was a reversal of an interpretation issued by Corbett's administration earlier this year, which said only patients with serious illnesses could keep their doctors.
Insurance Department spokesman Ron Ruman said he did not know if Highmark had requested a more specific definition of the provision or if state officials were reviewing any of the disputed claims.
But Ruman did say the administration was sticking to its interpretation of continuity of care.
Wood said Wolf's position is clear: “There is no Highmark role for determining continuity of care,” he said.
But Seay said that the agreement remains open to interpretation. “The new administration has to decide what's in the consent decree and what's not,” she said.
Alex Nixon is a staff writer for Trib Total Media.
