Dive Brief:
- A dispute over whether the University of Pittsburgh Medical Center (UPMC) is an in-network hospital for Highmark Inc.'s insurance customers has outlived a state-negotiated consent decree intended to settle the dispute and is behind the insurer's delays in processing more than 14,000 claims, according to the Pittsburgh Tribune-Review.
- Highmark has asked the state to determine whether some claims match language in the consent decree, which was supposed to eliminate confusion over when Highmark members can be treated at the lower, in-network rates. The insurer has held up claims since Jan. 1, the day Highmark's contract with UPMC expired. The state's determination is key, because out-of-network charges would be higher for patients, but in-network charges under the consent decree would be capped at 60% of the total bill.
- UPMC and Highmark have been tussling over the consent decree brokered by Pennsylvania Gov. Tom Corbett's administration and AG Kathleen Kane in 2014. The deal included language that allows Highmark's members to continue receiving care at UPMC, but the insurer has been pushing a narrow interpretation of the document—while UPMC has been angling for a broad one.
Dive Insight:
The consent decree was supposed to end the Highmark/UPMC dispute, but instead of nipping the crisis in the bud, it only served to give it a longer life. This particular negotiation was not unlike a divorce—the UPMC contract with Highmark was ending, and the decree was dividing up the marital assets. The only problem was, it still wasn't specific about who got the house and who got the car, and now the two parties are fighting over the keys. The AG may have to step in again to settle it more clearly.
As the healthcare industry continues to change, the relationships between insurers and providers are only going to get more murky, so this is not likely to be the last time a state's Attorney General steps in to mediate a turf war.