Newspaper article Pittsburgh Post-Gazette (Pittsburgh, PA)

STATE HEADS TO COURT TO FORCE ARBITRATION FOR UPMC, HIGHMARK SENIORS WON'T BE USED AS 'PAWNS,' WOLF SAYS [Corrected 04/30/15]

Newspaper article Pittsburgh Post-Gazette (Pittsburgh, PA)

STATE HEADS TO COURT TO FORCE ARBITRATION FOR UPMC, HIGHMARK SENIORS WON'T BE USED AS 'PAWNS,' WOLF SAYS [Corrected 04/30/15]

Article excerpt

HARRISBURG - State regulators asked the courts Monday to force health care giants UPMC and Highmark into arbitration to resolve alleged violations of state-mediated agreements governing their breakup.

In a filing in Commonwealth Court, the attorney general's office and the departments of insurance and health wrote that UPMC, Pittsburgh's largest hospital network, and Highmark, the state's largest health insurer, have not complied with the so-called consent decrees entered into in 2014. The agreements set rules for what would happen with coverage for various groups of patients as UPMC providers quit providing in-network coverage for Highmark policyholders as they had in the past.

Gov. Tom Wolf said in a statement Monday that UPMC's cancellation of its Medicare Advantage plan with Highmark had been "the final straw."

UPMC has told the state it will lock Highmark's Medicare Advantage customers - about 182,000 Western Pennsylvania seniors - out of its hospitals and clinics, starting Jan. 1, unless Highmark agrees to increase cancer payments to the hospital system.

Highmark announced in April 2014 that it would no longer pay certain "markups" on cancer care provided in hospital outpatient centers rather than doctors' offices. UPMC said this month that Highmark has failed to pay it $143 million, which it considers a breach of the consent decrees.

"I will not allow our most vulnerable citizens, especially seniors, to be used as pawns in the dispute between UPMC and Highmark," Mr. Wolf said in his statement.

If the disputes are not resolved quickly, the state said in its filing, consumers will not know which health plan to choose during the open enrollment period in the fall.

In addition to the issues of oncology payments and Medicare Advantage plans, the state pointed to less prominent disputes: setting in-network emergency room and trauma service rates and protocols; reimbursement rates for certain hospitals and a list of conditions that UPMC's specialists will treat; dealing with out-of- network disputes or unresolved claims; a definition of what "continuity of care" means; and a list of which UPMC physicians are in-network for Highmark's Medicare subscribers.

In response to the filing, Highmark and UPMC pointed fingers at each other.

"While UPMC agrees with the allegation as to Highmark, a careful review clearly demonstrates there's no substantive or legal basis for any of the Commonwealth's misinformed claims against UPMC," a UPMC statement said.

UPMC said that the recommendation of arbitration would not solve the problems between it and Highmark, and that the state had ignored complaints it had filed against Highmark.

"We think the governor's statement with regard to UPMC's decision against seniors speaks for itself," Highmark said in a statement. …

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