The following issues have been resolved over the last month, at least through June 30, 2019, which is the expiration date of the Consent Decrees entered into with the approval of the Commonwealth Court by the parties in June of 2014.

Continuity of Care.  An arbitration award, a copy of which is attached, provides as follows:

  • The need for a continuing course of treatment shall be determined, in the first instance, by the patient’s treating physician.
  • “In-Network” access to UPMC for Highmark members for a continuing course of treatment shall be available through June 30, 2019.
  • A Highmark member who is in a course of treatment for UPMC for a confirmed pregnancy on or before December 31, 2015 may continue to access UPMC on an in-network basis for maternity care, delivery, and postpartum related to that pregnancy.

Oncology payment issues have been resolved through combination of arbitration and settlement.

  • An arbitrator ruled (opinion attached) that Highmark owed UPMC Shadyside $24 million for oncology treatments provided since 2014.  The parties then agreed on a global resolution of the oncology payment issue equal to $188 million.
  • The parties have agreed upon new oncology payment rates going forward, but those rates have not been disclosed, at least as far as I know.
  • The crux of the issue was whether physician clinics or offices could be converted to and paid as hospital outpatient departments.  Commercial payment issues have been resolved by the parties.  Medicare has proposed to eliminate or reduce that differential in 2017 for federal healthcare programs.

The Pennsylvania Supreme Court (opinion attached) has ruled that Highmark Medicare Advantage members shall be treated as in-network for UPMC through June 30, 2019.

  • The Supreme Court affirmed a prior Commonwealth Court Opinion matter (copy of the Opinion attached).
  • The key issue is the interpretation of the vulnerable populations provision of the Consent Decrees reproduced:

“Vulnerable Populations – Highmark and UPMC mutually agree that vulnerable populations include: (i) consumers age 65 or older who are eligible or covered by Medicare, Medicare Advantage, (ii) Medigap health plans, (iii) Medicaid and (iv) CHIP.  With respect to Highmark covered vulnerable populations, UPMC shall continue to contract with Highmark at In-Network rates for all of its Hospital, physician and appropriate continuity of care services for CHIP, Highmark Signature 65, Medigap and commercial retiree carve out as long as Highmark does not make unilateral material changes to these programs.  UPMC shall treat all Medicare participating consumers as In-Network regardless of whether they have Medicare as their primary or secondary insurance.  Highmark acknowledges that UPMC reserves the right to withdraw from these arrangements if Highmark should take the position that it has the authority to revise the rates and fees payable under those arrangements unilaterally and materially.”

The key issue is sentence 3 which states “UPMC shall treat all Medicare participating consumers as In-Network regardless of whether they have Medicare as their primary or secondary insurance.”  Both the Supreme Court and the Commonwealth Court concluded that section applied to Highmark Medicare Advantage members.