University Times

UPMC officials are "seriously considering" a change that would eliminate the referral requirement for Pitt faculty and staff in UPMC Health Plan's point-of-service (POS) plan who see a specialist within the health plan's network.

Currently, the approximately 1,600 Pitt employees who are POS members must pay deductibles of $250 (for individuals) or $500 (for family coverage) — in addition to paying 20 percent of costs for their care — for seeing specialists outside or inside the UPMC Health Plan network without a referral.

The proposed change would bring the POS plan closer into line with UPMC Health Plan's Enhanced Access HMO option.

Pitt HMO members are charged a $25 co-payment if they self-refer themselves to specialists within the UPMC network. No co-pay is charged if the HMO member first gets a referral from his or her primary care physician. (For HMO members, the health plan does not cover care provided by non-network specialists.) Sandra McAnallen, UPMC Health Plan vice president of network and health service administration, wrote in a May 31 letter to then-University Senate President Nathan Hershey that the health plan is analyzing the potential financial impact of the change. "As a result of our study," she wrote, "UPMC Health Plan is seriously considering a process for our POS network similar to that which currently exists in our Enhanced Access HMO offering to the University. Once a final decision is made, we will work through the University's Human Resources office to notify the subscribers properly."

James W. Edgerton, Pitt's assistant vice chancellor for Compensation and Benefits, said Human Resources has been negotiating details of the change with UPMC Health Plan for the past year.

"We'd be willing to implement this change tomorrow, but UPMC needs to adjust their billing process and put together the administrative support" for the change, Edgerton said. "Probably, we won't see a final decision on this until the fall."

— Bruce Steele