As the latest dispute between the University of Pittsburgh Medical Center (UPMC) and insurer Highmark, Inc. drags on, the Pennsylvania Department of Health is considering compelling both entities into the mediation process to speed up settlement of the disagreement for the best interests of the patients.
The disagreement centers on the interpretation of language in health insurance policies covering “continuity of care.” The concept refers to conditions that require ongoing treatment by a UPMC doctor. The hospital staff would prefer to interpret this language as broadly as possible in order to provide continuous care to their patients, but Highmark insists that only serious illnesses should be considered covered by the “continuity of care” provision, and that preventive care and treatment of non-serious conditions should not require the more expensive UPMC treatments and could be handled by cheaper resources.
The Department of health is empowered to force both sides into mediation if there is no reasonable hope of a negotiated agreement. A prior consent decree signed by both UPMC and Highmark included a deadline of January 9, 2015 to come to a new agreement, thus giving the Department of Health the option of compelling mediation proceedings. The Department has stated it is evaluating both positions.
The decision will ultimately affect over one million people covered under Highmark’s plans. The cost differential between “in-network” and “out of network” coverage is considerable to Highmark, which would prefer that only emergency and necessary care be done at the out of network UPMC.