UPMC, Highmark face off over out-of-network prepayment rule: 5 things to know


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A state-brokered consent decree between Pittsburgh rivals Highmark Health and UPMC expires June 30, 2019, after which Highmark’s Medicare Advantage members will be unable to access UPMC at in-network rates. A recent report from Trib Live found the systems are clashing over a new rule concerning how some nonemergent care will be paid for by out-of-network Highmark members.

Here are five things to know:

1. Beginning in July, Highmark MA members will have to pay any estimated upfront charges for nonemergent treatment in full before accessing care from most UPMC providers, UPMC said in an Oct. 1 internal memo.

2. For example, a Highmark MA member wishing to schedule a surgery next July at most UPMC hospitals will have to request an estimate for the service from UPMC and pay it in full before undergoing surgery, according to Trib Live, which cites the internal memo.

3. Partial payments or arranged payment plans will not be accepted, according to UPMC. “If you choose to access nonemergency care from a UPMC provider that is out-of-network, you will be required to pay in advance,” a UPMC mailer sent to patients explains. It adds that patients can maintain in-network access to UPMC through plans sold by Aetna, its subsidiary Coventry, Cigna and UnitedHealthcare.

4. Highmark officials were surprised by the new rule. They told Trib Live the mandate is “an extremely unusual” move by UPMC. A Highmark spokesperson told the publication the rule runs counter to other “providers across the nation, when our Medicare Advantage members travel and may see an out-of-network provider.”

5. A UPMC spokesperson told Trib Live the system sent out the Oct. 1 memo to physicians “because we didn’t want any of their patients to be surprised.”


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