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UPMC and Highmark provider contract dispute

Most Recent News (July 2014)

 

On June 27, 2014 a consent decree was reached by UPMC and Highmark which provides for transition of care for members in the event that a continuing agreement between the two parties is not reached by December 31, 2014. This document addresses many of the issues concerning members in western Pennsylvania, including oncology services, emergency services, and services provided by certain medical providers in the area of pediatrics and behavioral health.


Information Previously Posted (April 2014)

How does this affect me?

The provider contract which is due to expire on December 31, 2014, controls the terms under which UPMC hospitals and physicians will provide services to Highmark members. 

If the provider contract expires on December 31, 2014, PASSHE employees and their dependent who have Highmark insurance (Highmark PPO Blue or Highmark Indemnity – Comprehensive Major Medical) will not have in-network access to most UPMC hospitals and physicians who will be classified as "non-participating providers".

Highmark and UPMC began to air extensive media campaigns in late spring/early summer of 2013.  The advertisements address the pending expiration of their commercial contract with one another on December 31, 2014.  Highmark’s ads call for an extension of the contract while UPMC ads state that there cannot be an extension for competitive reasons now that Highmark has purchased its own health care provider system.  Each has complained that the other’s position constitutes anti-competitive behavior.

  

Important Questions:

  

 

Provider Information​ ​

 

HIGHMARK PPO BLUE

888-745-3212
Click here to search the provider directory
Click here for the Highmark PPO Blue Summary of Benefits

UPMC HMO HEALTH PLAN

800-644-1046 Pre-enrollment questions
888-876-2756 Current members
Click here to search the provider directory
Click here for the UPMC Health Plan HMO Summary of Benefits
 

 

 
Employees and their dependents that are enrolled in either the Highmark Preferred Provider Organization (PPO) Plan or the Indemnity - Comprehensive Major Medical (CMM) Plan are generally eligible to be treated in UPMC’s hospitals and by UPMC physicians on an “in-network” or participating provider basis (see below) through December 31, 2014.  This means that UPMC will accept Highmark insurance coverage, subject to any co-payments or deductibles which are part of the applicable Highmark plan (PPO or CMM plan).
 
 
 
The PPO Plan utilizes a PPO network – any provider (hospital or physician) not part of the PPO network is considered "out-of-network"
 
In-Network Benefit:  Insurance companies contract with hospitals and physicians to form what is called a provider network.  If you use your Highmark PPO Blue insurance policy and get medical treatment from an “in-network” provider, you may be responsible to pay an office visit co-payment amount.  Highmark Blue Shield will then pay a negotiated dollar amount to the hospital or physician.  The hospital or physician will not be able to bill you for any difference between the negotiated rate and the actual cost of the services beyond your co-payment.  This is generally the most cost effective way to obtain hospital or physician services.
 
Out-of-Network Benefit:  Your hospital or physician is considered “out-of-network” if you get non-emergency medical treatment from a hospital or physician not participating with Highmark Blue Shield.  Highmark Blue Shield agrees to pay a specified dollar amount, or allowance, towards the cost of the medical services by a hospital or physician even if they do not have a contract with them.  Not all health plans offer this benefit.  More than likely, Highmark Blue Shield’s allowance will not cover the full cost of the medical services.  This out-of-network hospital or physician may bill you the difference between the charges for the health care services rendered and the amount paid by Highmark Blue Shield – this is called balance-billing, in addition to your deductible and co-insurance.  Before you obtain medical services out-of-network, please carefully investigate the costs you may incur.

 
PPO In-Network vs. Out-of-Network Examples
 
If you use an Out-of-Network provider:
·         You will be subject to the Out-of-Network deductible, which is $250 for an individual, up to $500 for the family – this is on an annual calendar year basis
·         You will be subject to the Out-of-Network coinsurance, which is 20% of the cost charged after the deductible has been met
·         You will be subject to an Out-of-Network Out of Pocket maximum limit, which is $1,500 for an individual, up to $3,000 for the family – this is on an annual calendar year basis
·         You may be subject to Balance Bill – the provider can bill the difference between the insurance allowance and their full charge, which can be significant
·         Co-payments do not apply – eligible services are subject to deductible and coinsurance
·         Routine Preventive care requires member cost share – eligible services are subject to deductible and coinsurance
·         You may be required to pay some or all of the cost of services at the time of the visit/service
 
Example – you have a surgical procedure e.g., knee replacement surgery
 
Example
If your provider is in the PPO In-Network
If your provider is
PPO Out-of-Network
Provider Charge
$50,000
$50,000
Allowed Charge by Highmark
$30,000
$30,000
Your Deductible
Does not apply ($0)
$250
Balance
$30,000
$29,750
Your Coinsurance
Does not apply ($0)
$1,500
20% up to out-of-pocket limit which is $1,500
Amount Paid by Highmark
$30,000
$28,250
Your Responsibility
Deductible
$0
$250
Coinsurance
$0
$1,500
Potential Balance Bill
$0
$20,000
Your TOTAL Cost
$0
$21,750
 
 
The CMM Plan utilizes participating vs. non-participating providers (hospital or physician)
 
Participating Provider Benefit:  Insurance companies contract with hospitals and physicians to form what is called a participating provider network.  If you use your Highmark CMM insurance policy and get medical treatment from a participating provider, you may be responsible to pay a deductible and co-insurance.   Highmark Blue Shield will then pay a negotiated dollar amount to the hospital or physician.  The hospital or physician will not be able to bill you for any difference between the negotiated rate and the actual cost of the services beyond your deductible and co-insurance.  This is generally the most cost effective way to obtain hospital or physician services.
 
Non-Participating Provider Benefit:  Your hospital or physician is considered non-participating if you get medical treatment from a hospital or physician not participating with Highmark Blue Shield.  Highmark Blue Shield agrees to pay a specified dollar amount, or allowance, towards the cost of the medical services by a hospital or physician even if they do not have a contract with them.   More than likely, Highmark Blue Shield’s allowance will not cover the full cost of the medical services.  This non-participating hospital or physician may bill you the difference between the charges for the health care services rendered and the amount paid by Highmark Blue Shield – this is called balance-billing, in addition to your deductible and co-insurance.  Before you obtain medical services from a non-participating provider, please carefully investigate the costs you may incur.
 
Comprehensive Major Medical (CMM) Participating Provider vs. Non-Participating Provider Examples
 
·         You will be subject to the deductible, which is $750 for an individual, up to $2,250 for the family – this is on an annual calendar year basis.  The same deductible applies to participating and non-participating provider claims.
·         You will be subject to the coinsurance, which is 20% of the cost charged after the deductible has been met.  The same co-insurance applies to participating and non-participating provider claims.
·         You will be subject to an Out of Pocket maximum limit, which is $750 for an individual, up to $2,250 for the family – this is on an annual calendar year basis.  The same Out of Pocket limit applies to participating and non-participating provider claims.
·         You may be subject to Balance Bill – the provider can bill the difference between the insurance allowance and their full charge, which can be significant
·         You may be required to pay some or all of the cost of services at the time of the visit/service

 
Example – you have a surgical procedure (i.e., knee replacement surgery):
If your provider is participating
If your provider is non-participating
Provider Charge
$50,000
$50,000
Allowed Charge by Highmark
$30,000
$30,000
Your Deductible
$750
$750
Balance
$29,250
$29,250
Your Coinsurance
$750
$750
20% up to out-of-pocket limit
Amount Paid by Highmark
$28,500
$28,500
Your Responsibility
Deductible
$750
$750
Coinsurance
$750
$750
Potential Balance Bill
$0
$20,000
Your TOTAL Cost
$1,500
$21,500
 
  
 
The UPMC HMO Health Plan is an alternative health plan available to most employees who live in the UPMC HMO Health Plan service area.  As you consider your health plan enrollment options, it’s important that you understand what is included in UPMC HMO Health Plan’s network.
 
The UPMC HMO Health Plan provider network includes the specialty hospitals of UPMC, but also includes many other facilities and providers in western Pennsylvania.  The network includes other community hospitals, physician practices, urgent care centers, behavioral health facilities, and long-term care facilities.  It DOES NOT include the Allegheny Health System facilities and doctors as part of the network. (Note: Highmark Blue Shield owns the Allegheny Health System). Members receive in-network access to more than 125 hospitals and more than 11,500 physicians in western Pennsylvania.  Click here to search the provider directory for UPMC HMO or to determine if your provider is part of the UPMC network.
 
The Enhanced Access HMO plan does not require a referral to see a specialist
 
Coverage outside of western Pennsylvania in the UPMC HMO Health Plan is very limited except in very specific situations.
 
·         All UPMC HMO Health Plan members are covered for urgent or emergency care no matter where they go.
 
·         Full-time college students are covered both within and outside western Pennsylvania.  Simply call a Health Care Concierge at UPMC who can help to set up coverage in the student’s area for any care he or she may need.
 
·         Membership in UPMC HMO Health Plan entitles you to a unique global emergency services program called Assist America.  This program protects members covered under the UPMC Health Plan with resources like doctors, hospitals, pharmacies and other services while traveling 100 miles or more from your home. 
 
Assist America is not travel or medical insurance – it is provider of global emergency services.  Assist America’s services do not replace medical insurance during medical emergencies away from home.  All medical costs incurred should be submitted to UPMC and are subject to the policy limits of your health coverage.   Click here to view the Assist America flyer.
 
Some of the key services include:
o   Medical consultation, evaluation and referral
o   Hospital admission assistance with non-US hospital admission
o   Emergency medical evacuation if adequate medical facilities are not available locally
o   Medical Repatriation – transport home or to a rehabilitation facility if you require medical assistance after being discharged from a hospital
 
If you will be traveling 100 miles or more from your home for more than 90 consecutive days, you will need to contact Assist America or UPMC for more information.

 
For transition of care from a UPMC professional provider to a non-UPMC provider -
There will be a formal Transition of Care policy that will be finalized by the end of July 2014, in the event that the contract between Highmark and UPMC expires on December 31, 2014.  Highmark has already put in place a pro-active (Highmark initiated) and reactive (member initiated) approach to assisting employees and their dependents who are experiencing physician disruption. 
 

What is an appropriate time frame for employees and their dependents that may want to transition from a UPMC professional provider to a non-UPMC provider?

While there is no specific time frame being proposed, Highmark is prepared to assist employees who wish to transition their care from one provider to another.   Highmark has created the My Care Navigator tool (Click here to access) to help employees find doctors, make appointments, transfer medical records, and more easily navigate the expansive network of physicians and other medical providers.   Because each situation between doctor and patient may be different and there are many variables that can come into play, Highmark recommends that employees begin to think about this situation and have conversations with their provider as soon as possible.  As we get closer to the potential end of the contract, Highmark will be communicating with employees exactly which doctors and facilities will not provide In-network access on 1/1/15.  As you know, there are several exception hospitals, doctors, and ancillary providers that will not have their contracts end on 12/31/14, and Highmark is fully committed to ensuring that employees are aware of these providers.  Highmark is also committed to ensuring that employees who may need assistance with the transition process are provided with the tools and resources they need to make informed decisions.       

 
There have been reports that there will be an affiliation between the Allegheny Health Network and Johns Hopkins University.  What is the effective date of affiliation? Do we expect there will actually be Johns Hopkins University providers/offices established in western PA at some point?
 
Allegheny Health Network and Johns Hopkins announced plans for a five-year cancer affiliation that is expected to be finalized in the next few months.  The two organizations will collaborate on an array of initiatives that will benefit cancer patients within Allegheny Health Network.
 
As part of the affiliation, it is anticipated that Hopkins will provide continuing medical education opportunities to physicians and nurses across Allegheny Health Network. In addition, Hopkins plans to offer a physician-to-physician consultation service to Allegheny Health Network’s clinicians for complex and rare cancer cases and provide patients with access to its clinical cancer trials. Joint projects designed to improve the quality and safety of cancer care also are planned.
 
As part of the future affiliation agreement, a fund for cancer research will be established that spans bench to bedside research interests at Johns Hopkins and Allegheny Health Network. Research will focus on basic science efforts to reveal cancer triggers and treatments, clinical trials of new treatments, and quality of life and survival outcomes research.

About the Johns Hopkins Kimmel Cancer Center

 

The Johns Hopkins Kimmel Cancer Center is a National Cancer Institute-designated comprehensive cancer center, for clinical collaborations, medical education and a broad range of cancer research initiatives. It is one of the nation’s 41 comprehensive cancer centers designated by the National Cancer Institute, and one of the first to earn that status. Research led by its faculty is among the most highly-cited in cancer research and clinical care. Hopkins has pioneered fields such as cancer genetics, bone marrow transplant medicine and cancer immunotherapy.
 
 
 
Through the national BlueCard program, Highmark members have in-network access to Blue Cross and Blue Shield facilities and physicians throughout the United States, including access to world class facilities such as Johns Hopkins Hospital, Cleveland Clinic, and many other highly recognized providers.  This includes over 5,700 hospitals and more than 1,000,000 physicians across the country. 
 
In addition, Highmark members also have access to Blue Cross and Blue Shield facilities and physicians around the world through the BlueCard Worldwide program. This arrangement includes 5,800 hospitals and more than 59,000 physicians globally.

 

 
 
PASSHE employees and their dependents enrolled as Highmark members will continue to have participating provider access to the following facilities beyond December 31, 2014. These facilities will continue to be participating providers beyond December 31, 2014.
 
UPMC Facility
Contract expires:
Children’s Hospital of Pittsburgh of UPMC
6/30/2022
UPMC Altoona
12/31/2019
UPMC Bedford
12/31/2019
UPMC Hamot and its affiliate Kane Community Hospital
12/31/2019
UPMC Horizon
12/31/2019
UPMC Northwest
12/31/2019
Western Psychiatric Institute and Clinic
12/31/2019
Hillman Cancer Center
12/31/2019
UPMC Mercy
6/30/2016
 
 
They will also have access to all other UMPC hospitals and physicians on a non-participating basis. The non-participating access will result in additional out-of-pocket costs for Highmark members.