Financial Impact Another Sticking Point in Breakup of Upmc-Highmark: Emergency Care Costs

By Twedt, Steve | Pittsburgh Post-Gazette (Pittsburgh, PA), January 22, 2018 | Go to article overview

Financial Impact Another Sticking Point in Breakup of Upmc-Highmark: Emergency Care Costs


Twedt, Steve, Pittsburgh Post-Gazette (Pittsburgh, PA)


Picture for a moment this unsettling scenario:

Some time after June 30, 2019, when Highmark and UPMC have finally gone their separate ways, a Highmark-insured pedestrian is seriously injured and unconscious after being struck by a car while crossing Fifth Avenue in Oakland.

Under federal law, UPMC Presbyterian - as the closest emergency room - is required to provide medical treatment until the person is stabilized and either transferred or sent home.

What the law does not require is that UPMC offer that service at a discounted rate.

Billing at a higher rate for out-of-network care is a common, industry-wide practice that generally comes into play when someone needs emergency medical treatment while vacationing out of the area. But in this setting, it holds its own broad - and potentially costly - implications for Highmark members in the Pittsburgh region, where a majority of the emergency rooms are in UPMC hospitals.

Unless Highmark and UPMC come to terms, that life-saving care could have a devastating impact on a patient's life savings.

So far, the two Pittsburgh health giants don't even agree on how the process works.

UPMC spokesman Paul Wood says when an out-of-network patient is treated at one of the health system's hospitals, "We charge the insurance company at the out-of-network rate." In the scenario above, Highmark would be billed the same as Florida Blue Cross Blue Shield would be if one of its members received care at UPMC, he said.

"The insurance company reimburses us for the charges and then the insurance company decides what part of the charge is going to be the member's responsibility."

Highmark, on the other hand, maintains that if a Highmark member receives emergency care at an out-of-network hospital, the provider - in this case UPMC - would bill the patient directly and Highmark would send the patient a check for the portion of the bill that it covers.

It then would be up to UPMC to decide what it will collect from the patient, said Highmark spokesman Aaron Billger.

Mr. Billger said Highmark has proposed an out-of-network reimbursement rate for its members' emergency care that would prevent any balance billing of patients, but it has not yet received a response from UPMC.

Mr. Wood said, "UPMC is in regular contact with Highmark, but we don't publicly discuss negotiations."

Highmark Health's Allegheny Health Network hospitals do have an agreement with UPMC Health Plan on reimbursement for out-of-network emergency care provided for UPMC insurance members. Those patients are not billed for any balance.

Kristine Grow, spokeswoman for America's Health Insurance Plans in Washington, D.C., said the general industry practice is that nonparticipating hospitals and other providers will bill the insurer "almost as a courtesy to the patient."

"However, they usually explain to the patient that, as they do not accept [that] insurance, they may not necessarily accept the level of insurance reimbursement as payment in full."

UPMC has eight local hospitals with emergency departments compared to five in Highmark's Allegheny Health Network. AHN does plan to include emergency departments in its planned four "neighborhood hospitals" and its 160-bed hospital in Pine. …

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