Physicians, Highmark continue discussion on reimbursement rates

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Both the Pennsylvania Medical Society and the Pennsylvania Academy of Family Physicians have sent letters to the state’s insurance department asking that it intervene with Highmark’s decision to reimburse providers 4.5 percent less for patients covered under the Affordable Care Act.

The Pennsylvania Insurance Department confirmed that it did receive both of the letters, but the organization does not have the power to approve or deny Highmark’s reimbursement rates, according to Deputy Press Secretary Ali Fogarty.

Despite the fact that the department doesn’t have control over Highmark’s decision now, the Medical Society’s intention is to make sure the department is aware of the impact that the rate increases have on physicians and patients, as it is their job to protect consumers, according to Michael Fraser, executive vice president of the society.

“They may not be able to do something now, but they do need to see that when they are reviewing proposed rate increases and making decisions about those increases in the future that their decisions have significant impact on physicians and patients,” Fraser said.

At the end of the day, physicians have no choice but to accept the fee reduction.

In most contracts between physicians and insurance companies, it is an all or nothing deal — if physicians participate in one product offered by the company, then they must participate in all of the products, Fraser explained.

“Ultimately, when those Highmark contracts are up for renewal, it is things like this that physicians have to weigh before they agree to participate in the future,” Fraser said. “And I know many physicians are doing just that — looking for other options and fairer contracts in the future.”

Discussions with Highmark

The need to discuss other options and future contracts prompted the Medical Society to also send a letter directly to Highmark requesting a meeting between their organizations and affiliated physician groups.

The first meeting is happening this week, as Highmark welcomes the opportunity for discussion, according to spokesman Leilyn Perri.

Highmark’s already explained that its decision to reduce its reimbursement rates is one of several attempts the company has made to address the losses it is experiencing from the ACA.

The company’s losses have now reached about $500 million, according to Alexis Miller, senior vice president of individual and small group business at Highmark. The losses are due to unexpectedly high use of services among those covered under the ACA.

In February, Highmark sent a letter to physicians notifying them of the reimbursement change, stating that the decision will go into effect April 1.

“We are committed to stabilizing our ACA line of business, and the recent fee schedule adjustment is one step toward keeping ACA plans viable,” Perri said. “Over the last two years, we have taken multiple actions on multiple fronts, and used significant reserves, to ensure a sustainable offering to individuals in the Commonwealth.”