Pennsylvania v. UPMC

The issue this case presented for the Pennsylvania Supreme Court’s review centered on review of a Commonwealth Court order Court interpreting a provision of a consent decree, negotiated by the Office of Attorney General of Pennsylvania ("OAG") and approved by the Commonwealth Court, between Appellant UPMC, a nonprofit health care corporation, and Appellee Highmark, a nonprofit medical insurance corporation, which established the obligations of both parties with respect to certain health care plans serving vulnerable populations. Specifically, the Court considered whether the Commonwealth Court erroneously interpreted this "vulnerable populations" provision as creating a contractual obligation for UPMC to treat all participants in Highmark’s "Medicare Advantage Plans" (for which Highmark and UPMC currently have provider contracts which UPMC has indicated it will terminate) as "in-network" for purposes of determining the rates it is permitted to charge these individuals for physician, hospital, and other medical services during the duration of the consent decree. After careful review, the Supreme Court affirmed the Commonwealth Court’s finding that the "vulnerable populations" clause of the consent decree required UPMC to "be in a contract" with Highmark for the duration of the consent decree, and, thus, that UPMC physicians, hospitals, and other services shall be treated as "in-network" for participants in Highmark Medicare Advantage plans which were subject to provider contracts between Highmark and UPMC set to be terminated by UPMC on December 31, 2015. The Court also affirmed the portion of the Commonwealth Court’s order requiring judicial approval for any further changes in business relationships between these parties which were governed by the consent decree, but quashed as not yet ripe for review the portion of the order which directed the OAG to file a request for supplemental relief to effectuate compliance with the consent decree. View "Pennsylvania v. UPMC" on Justia Law