UPMC to Ensure Patients Not Caught in Middle of Out-Of-Network Billing Issues Created by Highmark After June 30

By: Paul Wood

UPMC today informed the Pennsylvania Insurance Department and Highmark that it will not seek pre-payment from out-of-network Highmark Medicare Advantage members after the Consent Decrees end on June 30, 2019. Additionally, for out-of-network emergency care, UPMC will accept direct payment from Highmark at the same rate that UPMC Health Plan now pays Highmark’s Allegheny Health Network hospitals. These decisions were prompted by recent statements from Highmark indicating that it will pay UPMC directly and in full for many of these services and that it, like UPMC, wants to eliminate the need for “balance billing.”

“As the Consent Decrees near their end on June 30, our intent is to ensure that Highmark members can receive emergency and other care that they need without being caught in the middle of billing issues created by their insurer,” said UPMC Chief Communications Officer Paul Wood.

For Medicare Advantage members, UPMC will bill Highmark directly for out-of-network services and accept reimbursement at the Medicare fee schedule amount, subject to appropriate member cost sharing. For out-of-network emergency services provided to Highmark commercial members, UPMC will bill Highmark directly under the same contract rate that UPMC Health Plan now pays Highmark’s Allegheny Health Network hospitals.

Several years ago, UPMC Health Plan agreed to pay Highmark’s Allegheny Health Network hospitals directly under a negotiated contract rate to ensure that its members’ financial responsibility for emergency and related care would be limited only to appropriate cost-sharing, like co-pays and deductibles. That means that UPMC Health Plan members are not balance-billed by Highmark’s hospitals. UPMC will now adopt the same contract rate when billing Highmark directly for out-of-network emergency care, despite the lack of a formal agreement with Highmark.

“UPMC Health Plan does not allow its members to be placed in the middle and receive surprise medical bills when requiring out-of-network care,” said Wood. “Our action today should ensure that all patients, regardless of their insurer, are protected. Should Highmark fail to pay the billed amounts directly to UPMC, UPMC will have to reconsider its decisions regarding pre-payment and balance billing.”