Highmark vs. UPMC: The saga continues


"It's like fourth grade," Judge Dan Pellegrini said of a court hearing Wednesday regarding the ongoing dispute between Pittsburgh health giants Highmark and the University of Pittsburgh Medical Center.

The state wants Highmark to include UPMC providers at in-network rates, but the two sides disagreed about what it meant when both said seniors still would have access to UPMC providers, reports the Pittsburgh Post-Gazette.

The state asked the courts to order Highmark to stop marketing the Medicare Advantage "Community Blue" plan, a new, low-cost plan with a narrow network that excludes UPMC providers. This raised questions about whether states have authority to quash plans that the federal government approved.

The latest court wrangling had Pellegrini with his head in his hands. "Do you know how silly this proceeding sounds?" he asked. "It's all about money and it's all about market share. That's what this whole thing is about."

Highmark purchased UPMC's main competitor, West Penn Allegheny Health System, to offer more competition among providers. But UPMC refused to re-sign its contract with Highmark, saying reimbursement rates were too low.

After the two decided to stop working together this summer, they entered a consent decree, which says that Highmark's members can continue using UPMC providers at in-network rates. But the two sides would not even sit in the same room while that decree was crafted. Instead the state negotiated parallel agreements, one between the state and Highmark and the other between the state and UPMC.

The state maintains that Highmark is misleading consumers by not clearly explaining that its Medicare Advantage "Community Blue" plan doesn't include UPMC doctors and hospitals. Highmark argues that in giving customers a choice, that includes the opportunity to choose a different plan, one that does include UPMC.

Highmark earlier said the consent decree was simply a "framework" to help the companies transition consumers away from UPMC.

In testimony, Tom McGough, chief legal officer for UPMC, said Highmark is increasing premiums on its plans that include UPMC to push customers onto the new plan that does not.

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