Highmark plans to terminate its Pennsylvania contract with Rothman Institute on Oct. 1
The Pittsburgh insurer said 10,200 of its members have used Rothman services in the past year.
Highmark plans to end its Pennsylvania contract with Rothman Institute on Oct. 1, according to a letter to members. The insurer claimed that several Rothman surgeons had abused a federal process designed to protect patients from unforeseen out-of-network bills.
The dispute centers on the use of out-of-network physician assistants by Rothman physicians who do not have residents of fellows working for them and need help, Rothman president Alexander Vaccaro said in an interview Wednesday.
Rothman physicians are under contract with Highmark, but the physician assistants used by some doctors work for a separate company that Rothman has no control over, he said.
“Now they’re kicking us out, so now we’ll be that out-of-network provider. We will be that individual that Highmark is trying to go after,” Vaccaro said.
Asked for comment, Pittsburgh-based Highmark provided a copy of text it posted online in July:
“Highmark has identified issues with the billing and referral practices of several surgeons affiliated with the Rothman Institute, including deliberate abuses of the federal No Surprises Act and Independent Dispute Resolution process which have caused and can cause significant increased costs to Highmark and its self-insured clients.”
Highmark said Rothman’s failure to prevent the use of out-of-network providers represents a breach of contract that allows for the termination.
The dispute is bad news for James Pavlock, a retired federal prosecutor who has a form of Medicare supplemental insurance from Highmark that is affected by the dispute.
“It’s a big deal for me. I’m supposed to have surgery on Oct. 13. Do I go forward and pay thousands of dollars potentially?” the Fairmount resident said in an interview Tuesday, the day he received a letter from Highmark dates Sept. 2 about the termination.
Highmark’s July notice said 10,200 Highmark members had used Rothman services in the past year. Highmark said it will help patients in Pennsylvania find alternate sites of care.
Rothman will work with patients to use out-of-network benefits to continue receiving care from Rothman, Vaccaro said. The dispute with Highmark will not impact New Jersey patients, he said. Physician-owned Rothman is the largest orthopedic practice in the Philadelphia region.
Help for patients turned into controversy
Congress passed the No Surprises Act in 2020 to prevent patients from unexpected bills from out-of-network doctors when they receive care at an in-network hospital. This was a particular problem in emergency departments. The law has been successful on that front.
However, it also created what has turned out to be a controversial arbitration process to determine what insurers should pay out-of-network clinicians. Sometimes that has led to arbitration decisions for amounts that are many times the in-network price, according to the New York Times and other news outlets.
Rothman CEO Christian Ellison reiterated that the orthopedic practice has no involvement in the outside staffing companies at issue for Highmark. “We’ve received no financial benefit from any of this either, so we’re really on the outside looking in,” he said.
