Dive Brief:
- Highmark Health, Pennsylvania's largest insurer, has filed a lawsuit against the University of Pittsburgh Medical Center alleging that the provider overbilled chemotherapy treatments by $300 million since 2010.
- Highmark claims that UPMC billed the services as though they were being provided at an outpatient clinic (which can garner higher fees) even though they were rendered in a physician's office.
- The feud between the two parties began in 2011 when Highmark began acquisition of UPMC's biggest competitor, West Penn Allegheny Health System. UPMC chose not to renew its contract with the insurer and the two parties reached a state-brokered transition agreement June 24. The end of the contract has been "a bitter pill" to swallow for Highmark members who had expected continued in-network access to certain UPMC hospitals.
Dive Insight:
Billing for services at an outpatient clinic can be lucrative for hospitals, but patients and providers alike have been taking notice and questioning whether or not facility fees, which hike the price of outpatient care, should be allowed. Several ongoing lawsuits in Washington highlight the discrepancy in pricing in particular: In one case, the plaintiff was charged $1,133 for a service at an outpatient clinic that would have cost $269 in a physician’s office. In another suit, a patient was charged $8,189, of which almost $7,000 was a facility fee.
Highmark also released its post-transition plans this week, which UPMC is contesting.
Want to read more? You may enjoy this story on the Highmark Health Gamble: How risk is hospital-insurer integration?