While federal and state governments have wrestled with legislation to stamp out surprise medical bills, the issue apparently isn't a major problem in southwest Pennsylvania, according to a Pittsburgh Post-Gazette report.
"In southwest Pennsylvania, I think we're in such a unique situation with two [insurance/health] systems that people are just very aware that there's an in-network route, or an out-of-network route" to medical care, Lou Ann Jeremko, executive director of the Consumer Health Coalition in Pittsburgh, told the publication.
"They know the message is: 'You'd better come to us or pay out-of-network.'"
Southwest Pennsylvania is home of Pittsburgh-based UPMC health system — which owns UPMC Health Plan — and Pittsburgh-based insurer Highmark — which owns the Allegheny Health Network health system.
Ms. Jeremko said the systems are large enough now that "it's very rare with one or the other that there is a provider that is not in your network."
The Pennsylvania Department of Insurance received about 60 complaints about out-of-network bills in 2017 and 2018, and only nine were related to care provided in southwest Pennsylvania, according to the report, which cites department data.
UPMC spokesperson Susan Manko told the Post-Gazette the issue rarely occurs at UPMC "because almost all UPMC facilities utilize in-network ancillary providers."
"We rarely use non-UPMC physicians at our hospitals and provider sites. Otherwise, we would contract with the specialist to accept the payment as if in-network," she said.
Tom Fitzpatrick, a Highmark senior vice president involved in negotiating contracts with hospitals and other medical providers for Highmark, agreed that Highmark/Allegheny Health Network does not often deal with surprise out-of-network bills.
He told the Post-Gazette this is because of Allegheny Health Network's size and because most, if not all, hospital contracts with Highmark have "hold harmless" provisions in them that protect patients from surprise-billing situations. But he acknowledged some surprise bills have slipped through in the past.
Read the full Post-Gazette report here.
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