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Patients concerned about agreement between Highmark insurance and UPMC

PITTSBURGH — Earlier this year, Highmark and UPMC reached a deal to continue offering most Highmark patients in-network care at UPMC, but, it left some customers confused about what it meant for them. WPXI spoke to a woman who finally understood weeks after doctors diagnosed her with a rare cancer.

"We all thought Highmark, UPMC, they're one big happy family now," said Lori Ritter of Butler. "You know, their little quarrel, it's all over. Everybody's friends. But that's not the case."

Ritter didn't mince words about the Highmark-UPMC agreement reached this past June. She says the current state of health care in Pittsburgh creates too many roadblocks. She just found out she has a rare adrenal gland cancer, and her family‘s fear has turned to frustration because she has Highmark's Community Blue Flex health insurance.

"Even though they signed their agreement, it didn't help the people that have Community Blue Flex," said Ritter.

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Ritter's journey started in the emergency room last month when doctors discovered a tumor. She says their immediate recommendation was to see a specialist at UPMC.

"I felt that everything would be fine because they're like, 'Highmark would never turn you down treatment for a rare cancer such as the adrenal gland,'" said Ritter. "They would never do that. And I even questioned it a couple of times."

Ritter fully admits it's her responsibility to know what's covered, but considering her diagnosis, she wanted to see the specialist right away, who mapped out a treatment plan. Afterward, Ritter got a letter from Highmark saying she's been denied for in-network coverage. And that's because Highmark Community Blue Flex is considered a "narrow network" plan, which always excludes in-network access to UPMC — and the June agreement didn't change that.

But patients like Ritter were confused after hearing the deal's initial announcement.

"All UPMC hospitals and practitioners are now an option for Highmark's insured," said Pennsylvania Attorney General Josh Shapiro on June 24.

Ritter feels like she and about 300,000 Highmark patients on "narrow plans" have become the deals' fine print.

"I mean I'm fortunate to live in Pennsylvania to have all these fabulous doctors," said Ritter. "But then I'm unfortunate, that because of UPMC and Highmark, they can't get along."

As for her cancer, Highmark gave Ritter two options; go to an Allegheny Health Network in-network surgeon or see a doctor at the Cleveland Clinic, which she pointed out is more than two hours away. Her family would have to travel during the dead of winter, and UPMC is less than an hour away.

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Highmark spokesman Aaron Billger sent Channel 11 the following statement:

"Ms. Ritter is a valued member to us, and we've rallied around her diagnosis by helping her gain expedited access to in-network doctors and hospitals. We have never limited her access to UPMC; however, we have taken steps to explain how her health plan benefits work.

"With Ms. Ritter's benefits, she would have additional costs associated with out-of-network care. The choice of where she gets her care will be up to her. No matter her decision, our focus will remain on her whole health, and we will continue to surround her with care management and coordination."

The attorney general's office released this statement about Ritter's situation:

"We are working with this consumer on her complaint and doing our best to liaise with doctors and the health networks involved to ensure she gets the care necessary to address her health issues. My office is dedicated to addressing all Pennsylvanians access to affordable, quality healthcare."

So what should you be doing when selecting your health coverage?

  • Always talk to your employer about having options
  • Study your health plan
  • If you don't like what's offered, consider individual coverage you purchase on your own.