High­mark wins dis­pute with UPMC at Pa. Supreme Court

Modern Healthcare - - REGIONAL NEWS - —Lisa Schencker

Pitts­burgh-based UPMC must con­tinue to pro­vide in-net­work ser­vices to mem­bers of High­mark’s Medi­care Ad­van­tage plans, the Penn­syl­va­nia Supreme Court has ruled.

The rul­ing af­firms a state judge’s de­ci­sion in May that said the health sys­tem must re­main an in-net­work provider for High­mark’s Medi­care Ad­van­tage plans through 2019 un­der a con­sent de­cree reached be­tween the two bat­tling or­ga­ni­za­tions and the state last year. The state took UPMC to court af­ter the sys­tem an­nounced plans to end its Ad­van­tage con­tracts with High­mark be­cause the in­surer al­legedly failed to pay UPMC con­tracted rates for can­cer care.

As part of its case, UPMC al­leged that High­mark stopped pay­ing UPMC con­tracted rates for can­cer care and owed the sys­tem $143 mil­lion. The con­sent de­cree, UPMC ar­gued, al­lowed it to end its con­tracts un­der such cir­cum­stances.

The judges, how­ever, cited a clause within that con­sent agree­ment that says UPMC must con­tinue to con­tract with High­mark at in­net­work rates for High­mark’s “vul­ner­a­ble pop­u­la­tions.”

High­mark and UPMC have been feud­ing since High­mark, the largest health in­surer in the re­gion, ac­quired a ri­val health sys­tem— now Al­legheny Health Net­work—in 2013. A con­tract be­tween them ex­pired last year, and a tran­si­tion plan ap­proved by the Penn­syl­va­nia In­sur­ance Depart­ment out­lined which UPMC fa­cil­i­ties and ser­vices would be in­net­work and out-of-net­work af­ter the con­tract’s ex­pi­ra­tion. That fol­lowed a con­sent de­cree signed in June out­lin­ing sim­i­lar mea­sures.

High­mark pre­vails

in Medi­care case.

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