Pittsburgh-based Highmark Health and a regional GI practice have been unable to negotiate a new reimbursement contract, resulting in the practice’s exit from the Highmark network.
The financial sticking points have not been disclosed but the two sides said they are continuing to negotiate.
The practice is US Digestive Health, which has a clinical headquarters in Lancaster County and a management company based in Exton.
The previous reimbursement contract expired July 1.
In a statement, Highmark spokesperson Leilyn Perri said: “We have been negotiating to limit cost increases for our members and customers and to offer fair and reasonable reimbursement rates but have not been able to reach an agreement on a new contract. US Digestive Health’s “request for additional reimbursement will make it a significant outlier to the rest of our network.”
In an online FAQ, US Digestive Health argued that Highmark’s rates are lower than those of any other insurers with which the practice contracts.
The practice said its request for higher reimbursement is driven by rising costs of providing care, such as costs for staff, supplies and medication. “It’s important to know that these increases are only intended to cover those rising costs,” the medical practice said. “We are proud to offer affordable, high-value care to our patients, and we are committed to continuing that legacy.”
What’s the impact: For the time being, care at US Digestive Health is no longer covered by Highmark plans sold in the commercial, Medicaid, Medicare and Affordable Care Act markets in Pennsylvania and Delaware.
However, in online communications, both Highmark and US Digestive Health note that patients in certain situations, including those in active treatment, can apply to have coverage continue at in-network rates for a certain period of time.
The period is generally 90 days, according to Highmark.
“Our priority is ensuring that every patient maintains access to comprehensive high-quality gastrointestinal care,” Dr. Dale Whitebloom, chief medical officer for US Digestive Health, said in a statement. “We want to assure our patients that we are taking all necessary steps to minimize disruption and provide individualized care and planning.”
The background: Based in Pittsburgh, Highmark and its affiliates provide insurance to about 7 million people in Pennsylvania, Delaware, New York and West Virginia.
US Digestive Health was formed in 2019 by three GI practices: Regional GI in Lancaster County, Digestive Disease Associates in Berks County, and Main Line Gastroenterology in the Philadelphia area.
Backed by Greenwich, Connecticut-based private equity firm Amulet Capital Partners, the group now includes more than 40 locations in Pennsylvania and Delaware.
Its local offices are in Lancaster and York counties.