Highmark unveils details of UPMC breakup plan

Health insurer Highmark has released its final breakup plan with provider giant UPMC, a plan that largely falls in line with terms outlined earlier this summer and winds down a heated feud, although barbs continue to fly between the two sides.

Effective Jan. 1, the current contract between UPMC and Highmark expires. The two powerhouses have wrestled over in-network and out-of-network options for Highmark patients since Highmark agreed to acquire West Penn Allegheny Health System—a financially beleaguered system that is UPMC's main competitor. Highmark has since renamed it Allegheny Health Network.

The transition plan (PDF), approved by the Pennsylvania Insurance Department, outlines which UPMC facilities and services will be covered at lower in-network rates, and which will be out of network and thus cost patients more money.

Many of the components of the plan are similar to the consent decree that UPMC and Highmark signed in late June. UPMC's six flagship hospitals will become out-of-network next year, but there are seven “exception hospitals” across nine campuses outside of the Pittsburgh area that will be in-network facilities. Highmark and UPMC are negotiating those rates. However, Highmark patients will receive in-network care at all of UPMC's emergency rooms until they are discharged, including any related inpatient admissions. But patients will be transferred to Highmark's in-network facilities if necessary.

Highmark also said its network will include 81% of UPMC physicians, including all UPMC-employed oncologists, ER physicians, pediatricians and behavioral health specialists. Members who want to know which doctors are in network can go to Highmark's YourNetwork2015.com.

Some Medicare Advantage and Medicaid members will continue to receive in-network rates at UPMC facilities and physicians after the year ends. Highmark also will offer a new health insurance product, Community Blue Flex, that will tier benefits and cost-sharing at different UPMC providers.

Although many parts of Highmark's plan are similar from June's consent decree, UPMC spokesman Paul Wood called it “the most subscriber-unfriendly plan” Highmark could offer to members. He also contended that Highmark's analysis that 81% of UPMC physicians will remain in network is “much, much less” when looking at the plan.

For example, Highmark's provider website lists UPMC Chief Medical Officer Steven Shapiro as an in-network physician. But Wood said Shapiro has only performed procedures at UPMC's flagship hospitals, which would put him out of network.

“That is just deceptive and misleading to the consumer,” Wood said.

Not so, said Highmark spokesman Aaron Billger. The transition plan protects patients as much as possible from high out-of-network rates and gives them a wide net of care options, he said.

“The roadmap that has been set forth in the transition provides an opportunity for Highmark to offer an array of products at various price points to meet consumer needs,” Billger said. “We will have a tiered product, but they will still be protected from excessive charges.”

Follow Bob Herman on Twitter: @MHbherman