Pennsylvania regulators say Highmark plan for seniors violates agreement; insurer says 'wrong'

The Pennsylvania attorney general's office and two other agencies asked a judge Friday to order Highmark Inc. to let participants in its new plan for seniors use doctors who work for the University of Pittsburgh Medical Center.

UPMC is a competitor of Highmark's in the insurance business, but the attorney general and the departments of Health and Insurance say Highmark's insurance plan violates a consent agreement made this summer. They filed a request in Commonwealth Court that Highmark be held in contempt.

The filing argued that Highmark is in "selective compliance" through Community Blue, a Medicare Advantage HMO product for seniors. The state agencies want Highmark to include UPMC in Community Blue's provider network.

UPMC is the largest network in western Pennsylvania, with 22 hospitals. Highmark recently acquired seven hospitals in the region, known as the Allegheny Health Network.

In June, UPMC agreed to allow some Highmark insurance customers to continue using its doctors and facilities at in-network rates, in an effort to resolve a bitter fight between the western Pennsylvania health care operations.

The state agencies said Highmark's actions violated terms that address unclear or misleading advertising, mandatory service for at-risk people and provisions related to emergency rooms, oncology and certain hospitals.

"Highmark should not be permitted to fail to provide the agreed protections for the vulnerable population due to its unilateral interpretation of the consent decree and instead should be found to be in breach of the consent decree," the agencies wrote.

Highmark spokesman Aaron Billger said the consent agreement has not been violated and said the state is trying to dictate the design of its products. The company said the consent decree was a framework that left them latitude to meet the needs of patients.

"We believe that this is the wrong action at the wrong time for seniors," Billger said. "The commonwealth, frankly, is seeking to dictate product design here."