UPMC’s Taking Snit With Highmark Out On Patients?

By J.J. Jackson

In the Greater Pittsburgh area, the University of Pittsburgh Medical Center (UPMC) is well known. Sometimes however it is not known for the best of reasons. While UPMC has many good doctors that work for it and is known for good quality care, it is also often cursed for what it has done. For years and years UPMC has been gobbling up as many regional hospitals and doctor’s offices under its own banner as it can.

Often UPMC’s actions seem good. They swoop in to save smaller independent offices that are struggling under economic and regulatory burdens. In the early days this was praised. Now that so many facilities have been taken over it is hard to have a conversation about health care in the Pittsburgh area without UPMC’s name being taken in vain multiple times. Just randomly talking to people I have known over the years has led to a collection of many stories about how after so-and-so’s family doctor became a UPMC facility the waiting room became overly crowded and how appointments were no longer kept in a timely manner. That 5:00 PM appointment you thought you had slowly and painfully became a 7:00 PM one as you sit and sit and wait and wait. Then there are the stories about how customer service went to pot and how it is nearly impossible to get appointments for routine examinations without getting up early in the morning and trying to get through busy phone lines for a same day appointment.

The impression in Pittsburgh is that the unspoken doctrine of UPMC is that they want to be the sole provider of medical care in the region and put out of business other, smaller systems such as Ohio Valley Medical System and West Penn Allegheny. And, let me make sure everyone understands, there is nothing wrong with that. It is called the free markets.

Recently, UPMC made headlines when it refused to negotiate a new contract with the area’s largest medical insurance provider. That insurer is Highmark Blue Cross/Blue Shield. UPMC should of course be free to negotiate contracts with whomever it wants. However it’s reasoning for not negotiating with Highmark quickly perked up the ears of Pittsburghers already suspicious of them. That reasoning was also discovered quickly to be hypocritical.

As it goes, Highmark recently decided to invest money in struggling West Penn Allegheny’s system of hospitals. UPMC turned up its nose and denounced Highmark for the action and said it would not, under any circumstances, negotiate with an entity it now saw as a “competitor”. There is only one problem with this claim though. See, UPMC offers its own health insurance alternatives called the UPMC Health Plan. This health plan has long been in existence. So Highmark and UPMC have been “competitors” long before Highmark’s investment in one of UPMC’s competitors in the sector of hospitals. Yet year after year UPMC negotiated with Highmark anyway.

In fact, when you look at what UPMC has done, they have said that they will not do business with someone who both provides hospital services and health insurance options while they themselves offer hospital services and health insurance options. That’s fine. It is their choice.

However people who use Highmark as their service provider for health insurance are going to see, unless UPMC negotiates a new contract, themselves unable to access UPMC facilities as in-network providers and pay higher costs for care. The cynical, and I would call intelligent, people in Pittsburgh see this as UPMC trying to throw its weight around to either bring down Highmark, causing their subscribers to flee the service in order to access hundreds of facilities under the UPMC banner without added costs, or bring down the financially struggling West Penn Allegheny hospital system and destroy yet another competitor. Either way, UPMC wins.

But it seems that UPMC is upping the ante. While you expect businesses to fight it out among themselves, UPMC appears to also be taking out their snit with Highmark on those who have Highmark’s insurance plans.

Recently, despite years of never having a problem at UPMC facilities, my family has now witnessed recently UPMC’s apparent attack on Highmark insurance holders not once, but twice in recent months. Both have been billing disputes and note that we have not had billing problems in the past. So that makes these two recent problems all the more suspicious. It is almost as if UPMC is attempting to make me upset with Highmark for denying payments for services that should be clearly covered. I know, how cynical of me right?

The first incident was a couple months ago. Charlotte, my daughter, did something stupid. She stuck one of those little plastic beads that people often put in their hair up her nose. It promptly got stuck and stuck good. We took her to UPMC’s Children’s Hospital after the local emergency room at Forbes Regional Medical Center (West Penn Allegheny) was unable to remove it and told us that they would not be able to operate until the morning. Thinking we might be able to get quicker care elsewhere we had them transfer us knowing that there was always the possibility that the bead could travel deeper into nasal cavity and even into the brain cavity if left unchecked for an evening.

Upon arriving at Children’s my daughter was admitted (somewhere around 1:00AM in the morning) and we were told that in the morning they would operate to remove the bead. Of course, since there were higher priority cases to deal with, and I understand that, the surgery was pushed back several hours until the afternoon. So much for quicker care at UPMC right? Well, my daughter eventually went under anesthesia and with a pair of tweezers the offending bead was swiftly removed. We were sent home.

A few weeks later, a bill from Children’s Hospital arrived claiming we owed $100 for our co-pay. Not so fast I thought. Emergency Room visits, which is what this was, had the $100 co-pay waived if the patient was admitted. It says this right in my explanation of benefits brochure from Highmark. So my wife immediately called the insurance provider to inquire and to complain of the charge. Highmark them informed us that the $100 co-pay was because our daughter, according to the code UPMC used, was never admitted to the hospital but rather simply “put under observation.”

Huh? How do you do surgery on someone without admitting them? Well, a second call to complain to UPMC got the code changed to the correct one as my wife, who is a nurse, explained to them that what they were claiming was impossible. Problem solved. But it was still a little suspicious. You cannot tell me that UPMC made such a simple mistake except on purpose. Especially considering what has happened next.

Last month my daughter went to the family doctor, which became a UPMC facility a couple years back, for her annual check up. This was a standard, run of the mill well child visit. Nothing fancy at all.

She gets some shots and the doctor checks her out proclaiming her a perfectly healthy four year old girl. We go home.

A week later we get a benefits summary from Highmark. Several items are denied. Actually, they are the same item, mysteriously listed twice as “Developmental Testing” and labeled as code 96110 at $237 each. Now the fact that this service was listed twice on the same bill raised several red flags and Highmark’s remarks said the services were denied for payment because “the patient” was not “within certain age ranges, meets certain risk factors, or is of a specific gender.”

Again, my Highmark membership brochure clearly states that Pediatric care is fully covered for “Routine physical examinations, regardless of medical necessity and appropriateness and other items and services.” We wait for the inevitable bill from UPMC. It comes. Not only are they asking for this $237 charge to be paid twice, but also another $26 found no where on our Highmark statement. It comes out, continently, to $500.

So of course at this point I am pretty upset with Highmark and have our company’s HR department call and protest. Highmark responds back that the problem, once again, is the code that UPMC used. The code entered was for non-routine care.

With information in hand the wife, again a nurse who understands these codes and services better than I, was sicked on the doctor’s office. UPMC’s response is that they will have to resubmit the claim though the coding department and that there was no guarantee, of course, that after reviewing the services they would be recoded.

But I knew that would be their answer. The night before my wife and I had discussed what to do if they would not correctly code the services from the visit. We both agreed that we would not, under any circumstances, pay the bill. My wife informed them of this during the call. They had two options. Either they would recode the visit properly and get paid through the insurance OR they keep the existing bogus codes and get not a dime of what they want. Plus, they will promptly lose four patients.

UPMC tap danced and told her that the bill was on hold for the next 5 to 10 days while it was reviewed. No, no, no, UPMC you do not get it.

Time for me to get on my soapbox and use the rest of this article to inform UPMC what will happen.

Let me make this clear to you here publicly. IF after that review period you refuse to code the visit properly, continue to double charge us for the same service twice and send us a new bill that reads anything other than Total Amount Due: $0 you will not get a dime from us.

If, should you continue to try to bill us for these services by purposefully miscoding the purpose of the visit so that Highmark rejects it and as I have threatened to do, not to pay you, you want to ding my credit, I encourage you to do that. Because I will haul your little pink butts down to the court house so fast your heads will spin. And you can explain to the judge why you are playing games to try and get me upset with Highmark because you want to have a tantrum over who they are investing in.

I am sure your lawyer costs for handling such a case will be well in excess of the $500 you want to try and fleece me for. I am not going to let you get away with this. And you can bet I can make your lives a miserable Hell over something that should not be happening and seems to be a pattern with your company these days.

I am all for UPMC making money. I am all for UPMC doing their damnedest to put their competitors out of business if they cannot compete. But what I am not for is what I consider insurance fraud on UPMC’s part by misrepresenting services rendered.

After talking to several others with Highmark insurance this seems to be a pattern of behavior from UPMC as of late. All of a sudden bills for procedures never before questioned are getting rejected by Highmark over code issues.

I will not stand for it. And I am not the guy you want to mess with. As you can see I have a blog, a sizable syndication network, and I am not at all afraid to us either of them.

I await my bill for $0. Have a nice day!

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J.J. Jackson is a libertarian conservative author from Pittsburgh , PA who has been writing and promoting individual liberty since 1993 and is President of Land of the Free Studios, Inc. He is the Pittsburgh Conservative Examiner for Examiner.com. He is also the owner of The Right Things - Conservative T-shirts & Gifts The Right Things. His weekly commentary along with exclusives not available anywhere else can be found at Liberty Reborn.