Frequently Asked Questions (FAQs) and Updates
Here, you can learn more and stay up to date on the status of the Highmark and US Digestive Health negotiation.
We have not been able to come to a resolution with Highmark and are now considered an out-of-network provider for patients with Highmark health insurance July 1.
As stated in Highmark’s letter to patients dated July 23, 2024, Highmark is not granting its members access to BlueCard benefits in WV, PA, and DE to see USDH Providers. As a result, you may have higher out of pocket expenses.
What is happening?
US Digestive Health is committed to giving our patients the highest possible level of care. Our patients are at the center of everything we do – from creating a thoughtful care experience to leading cutting-edge clinical research for a better, healthier tomorrow. However, like many providers, we are facing financial pressures from the rising cost to provide patient care. We need Highmark to pay us fairly for the care we provide, so that we can continue to invest in the best possible outcomes for our patients.
We understand that the uncertainty insurance contract negotiation can cause for patients is challenging and even stressful. Please know we will continue to advocate for you, our Highmark patients, to regain in-network access to the GI specialists and care teams you know and trust.
What are the negotiations about?
When a provider agrees to accept the plans the insurer offers, they become part of the insurance company’s “network”. Both parties agree to certain amounts the insurance company will pay the provider for the care offered to patients who are covered by those insurance plans. After caring for a patient, the provider bills each patient’s insurance for the services provided, and the insurance company pays the provider for the patient’s care based on the rates that were agreed to in the contract. The amount an insurance company pays a provider for patient care services is called a payment or reimbursement rate.
These payment rates are regularly re-negotiated every few years when contracts expire because the cost for the provider to offer patient care changes each year based on many economic factors. Cost of patient care is impacted by things like the cost of staffing, supplies and drugs.
Why are US Digestive Health and Highmark negotiating payment rates?
Right now, due to inflation and the rising cost of things that are critical to patient care like staff, supplies and drugs, providers across the country are facing unprecedented financial challenges. As the cost of care increases, payments from insurance companies must increase too.
Highmark’s current payments do not cover the rising costs of providing patient care, which is why we are negotiating. It’s important to know that these increases are only intended to cover those rising costs. We are proud to offer affordable, high value care to our patients, and we are committed to continuing that legacy.
Is Highmark Profitable?
Highmark reported $533 million in profit in 2023.
Highmark pays US Digestive Health less than any of our other insurance company partners. In the face of the rising cost for patient care, Highmark must do its part through fair payment rates so that we can continue to invest in the highest level of patient care, new technology, equipment, and facilities.
What types of Highmark health insurance plans are impacted by this negotiation?
All patients with Highmark Commercial insurance, Medicare, Medicaid and Exchange plans are impacted by the negotiation.
However Delaware patients with Medicaid may have the option to change their health insurance plan to a different plan that definitively includes US Digestive Health in their network: Accepted Insurance Plans
FOR DELAWARE MEDICAID (HIGHMARK HEALTH OPTIONS) PATIENTS
- Patients with Medicaid in Delaware are able to change or update their insurance plan within 90 days of Medicaid acceptance, which means you may have the opportunity to switch to another insurance plan that includes US Digestive Health in their network – allowing you to keep seeing your US Digestive Health doctors and care teams on an in-network basis.
- Call your Delaware Health Manager at 1-800-996-9969 to learn more and get help switching your plan.
Which US Digestive Health facilities and providers are impacted by this negotiation?
All US Digestive Health providers in Pennsylvania and Delaware are impacted by this negotiation, including those formerly providing services under:
- Southwestern Gastroenterology Associates
- Delaware Center for Digestive Care
- Blair Gastroenterology Associates
- Gastrointestinal Specialists of Delaware
- Dr Richard Caruso of EHG – Lewes
When will the negotiation be resolved?
While our goal is to resolve the negotiation as quickly as possible to help avoid any prolonged impact for our patients, we need Highmark to understand our sense of urgency, and participate productively in the negotiation to hopefully come to an agreement in a timely manner. Please know, we have been doing everything we can to come to an agreement with Highmark, but we need Highmark to do the same.
However, at this time, our current contract ended effective July 1, 2024.
As stated in Highmark’s letter to patients dated July 23, 2024, Highmark is not granting its members access to BlueCard benefits in WV, PA, and DE to see USDH Providers. As a result, you may have higher out of pocket expenses.
We also strongly encourage you to call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your US Digestive Health providers.
What does it mean to be “out of network”?
At this time, our current contract has ended effective July 1, 2024 and US Digestive Health is considered an out-of-network provider for patients with Highmark health insurance. This means that some of our patients will be forced to pay higher out-of-pocket costs if they continue to see their US Digestive Health GI specialists and care teams.
Patients with certain conditions, such as those who are hospitalized, pregnant, or undergoing an active course of treatment, may be eligible for Continuity of Care which allows approved patients the opportunity to continue seeing their current care team at in-network rates for a certain period, even if US Digestive Health is out of network with Highmark. Patients should contact Highmark and must apply for Continuity of Care through Highmark. Highmark will review and approve or deny those applications on a case-by-case basis. The Centers for Medicare and Medicare Services (CMS) and other laws require insurance companies to extend coverage for certain patients if their provider is forced out of network by their insurance company.
We also strongly encourage you to call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your US Digestive Health providers.
If you have an appointment scheduled after July 1 or would like to schedule a future appointment, please call our hotline at (610) 871-3008, or call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your USDH providers.
HOW CAN HIGHMARK PATIENTS CONTINUE TO HAVE IN NETWORK COVERAGE?
Patients with certain conditions, such as those who are hospitalized, pregnant, or undergoing an active course of treatment, may be eligible for Continuity of Care which allows approved patients the opportunity to continue seeing their current care team at in-network rates for a certain period, even if US Digestive Health is out of network with Highmark. Patients should contact Highmark and must apply for Continuity of Care through Highmark. Highmark will review and approve or deny those applications on a case-by-case basis. The Centers for Medicare and Medicare Services (CMS) and other laws require insurance companies to extend coverage for certain patients if their provider is forced out of network by their insurance company.
I received a letter about the negotiation in the mail but I don’t have a Highmark Health insurance plan, I have another Blue Cross / Blue Shield Product, will I be impacted?
No. Out of State Blue Cross Blue Shield insurance, Capital Blue Cross, and Independence Blue Cross products are not impacted by the negotiation.
Can I still see my providers during the negotiation?
At this time, US Digestive Health is considered an out-of-network provider for patients with Highmark health insurance. This means that those patients and their families may have to pay more out of pocket for the care they need.
We also strongly encourage you to call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your US Digestive Health providers.
I offer Highmark Commercial health insurance to my employees and am getting close to my plan renewal period. What do I need to know or do to help make a coverage decision that keeps US Digestive Health in network?
Talk to your broker and consider all your options for your 2025 benefits selection. In these situations, sometimes people choose other insurance coverage, and sometimes employers offer a second option.
We are in network with all other major Commercial health plans:
- PA Insurances
- Aetna Commercial
- Aetna Coventry MC
- Aetna Premier Care Network
- Amerihealth Administrators
- Amerihealth Caritas CHC
- Amerihealth Caritas PA
- Amerihealth Caritas VIP Care
- Capital Blue Cross
- Capital Blue Cross Blue Journey MC
- ChampVA
- Cigna Healthcare
- Cigna Healthspring
- Devon/Contigo Health
- Devoted Health
- First Health Network
- Geisinger Family Plan
- Geisinger Gold
- Geisinger Health Plan Commercial
- Geisinger Kids
- Health Partners MA/Jefferson Health MA
- Health Partners MC/Jefferson Health MC
- Highmark Wholecare MA
- Highmark Wholecare MC
- Humana Choice Care
- Humana Commercial
- Humana Gold
- IBC
- Independence Administrators
- Keystone 65
- Keystone First
- Keystone First CHC
- Keystone First VIP
- Keystone Healthplan Central
- Keystone Healthplan East
- Loomis Company
- Medicaid PA
- Medicare – Railroad
- Medicare Novitas
- Multiplan/PHCS
- PA H&W Allwell
- PA H&W Ambetter
- PA H&W CHC
- Personal Choice
- Preferred Health Care
- Prime Health Services
- Senior Life
- Teamsters H&W Fund
- Tricare East/Humana Military
- UHC Community of PA
- UHC Dual Complete of PA
- UHC One
- United Healthcare Commercial
- United Healthcare MA
- United Healthcare MC
- UPMC Comm & MC
- UPMC for You MA
- UPMC HMO Premier RX
- WellSpan Population Health
- DE Insurances
- Aetna Commercial
- Amerihealth Caritas DE
- Cigna Healthcare
- Cigna Healthspring
- Delaware First Health
- Humana HMO
- Humana PPO
- Medicaid DE
- Medicare – Railroad
- Medicare Novitas
- Oxford Health Plan
- Tricare East/Humana Military
- United Healthcare Commercial
- United Healthcare MA
- United Healthcare MC
What if I’m receiving critical care for a chronic or complex illness that will require care after July 1, 2024?
We understand that many of our digestive health patients are managing chronic or complex conditions and that continuity of care with the doctors and providers our patients know and trust is extremely important.
Patients with certain conditions, such as those who are hospitalized, pregnant, or undergoing an active course of treatment, may be eligible for Continuity of Care which allows approved patients the opportunity to continue seeing their current care team at in-network rates for a certain period, even if US Digestive Health is out of network with Highmark. Patients should contact Highmark and must apply for Continuity of Care through Highmark. Highmark will review and approve or deny those applications on a case-by-case basis. The Centers for Medicare and Medicare Services (CMS) and other laws require insurance companies to extend coverage for certain patients if their provider is forced out of network by their insurance company.
If you have an appointment scheduled after July 1 or would like to schedule a future appointment, please call our hotline at (610) 871-3008, or call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your USDH providers.
Should patients with Highmark insurance reschedule existing appointments or stop scheduling future appointments?
US Digestive Health is considered an out-of-network provider for patients with Highmark health insurance effective July 1, 2024.
If you have an appointment scheduled after July 1, or would like to schedule a future appointment, please call our hotline at (610) 871-3008 or call Highmark at the number on the back of your insurance card to learn more about your benefits and out-of-pocket costs before you continue seeing your USDH providers. If you have employer-sponsored health insurance, you can always talk to your HR department, too.
How does the No Surprises Act impact patients with Highmark insurance?
(Via CMS) The Act protects you from unexpected out-of-network bills from:
- Emergency room visits
- Non-emergency care related to a visit to an in-network:
- Hospital
- Hospital outpatient department
- Ambulatory surgical center
- Air ambulance services
This may reduce your potential out-of-pocket costs.
Consumer Overview: Know your rights with insurance | CMS
Definitions of key terms in the No Surprises Act: No Surprises: (cms.gov)
What can I do to protect my in-network access to my US Digestive Health doctor?
There are several things you can do to make your voice heard on this issue:
- Call Highmark at the number on the back of your insurance card and tell them how important it is to keep US Digestive Health in network.
- Talk to your employer. If you have commercial health insurance through your employer, contact them to let them know it’s important that you and your family keep in-network access to the US Digestive Health facilities and doctors you know and trust.
- Call your broker. If you have Medicare Advantage, let them know you deserve to get the coverage you need, which includes having US Digestive Health in network. ACCEPTED INSURANCE PLANS
- For DELAWARE Medicaid Patients
- Patients with Medicaid in Delaware are able to change or update their insurance plan within 90 days of Medicaid acceptance, which means you may have the opportunity to switch to another insurance plan that includes US Digestive Health in their network – allowing you to keep seeing your US Digestive Health doctors and care teams on an in-network basis.
- Call your Delaware Health Manager at 1-800-996-9969 to learn more and get help switching your plan
How can I stay up to date on the US Digestive Health negotiation?
For more information on the progress of the negotiation, please continue to visit this page, and be sure to read texts from US Digestive Health for important updates. You can also continue to visit our website at protectdigestivecare.com or call our dedicated patient hotline with additional questions at (610) 871-3008.
