UPMC is committed to providing patients with the information they need to make informed decisions about their care. While many health insurers provide their members with full, in-network access to UPMC, there are certain types of health insurance plans and other products, including those that use unilateral repricing, that do not. Unilateral repricing plans are out-of-network with UPMC hospitals and facilities.
When UPMC refers to a unilateral repricing plan — sometimes called a “reference-based pricing” plan — it means a plan that, as a general rule, chooses not to contract with hospitals or health care facilities. Rather, these plans decide unilaterally how much to pay out-of-network hospitals or facilities for a patient’s care. When these plans pay the hospital, facility, or doctor less than the amount owing for that care, they put the patient in the middle of a billing dispute. These plans force health care providers to recover any unpaid amounts (beyond copays, coinsurance, or deductibles) directly from the patient.
UPMC requires payment in advance from patients who wish to schedule out-of-network care.
Please Note: If a plan is not listed, that does not mean that it is in-network. The best way for a member to check provider network status is to ask their plan.
A UPMC hospital, facility, or physician that has no contract with your insurance company or health plan administrator — which could be a third-party administrator, or “TPA” (see below) — is referred to as “out-of-network.”
It is important to ask whether the specific UPMC hospital, facility, or physician is “in-network.” You can reach out to your plan directly, using the number on your card. If your insurance is provided through your employer, you may also want to direct this question to your employee benefits representative.
No. While some unilateral repricing plans say that plan members are free to go to any hospital or doctor, that does not mean that your care will be in-network. If your plan does not have a contract with a UPMC hospital, facility, or doctor, your care will be out-of-network and you will be required to pay in advance for all nonemergent care.
A third-party administrator delivers various services on behalf of health insurance plans — often self-insured health plans — which may include the design, launch, and management of the health plans. Some TPAs are now using unilateral repricing plans to set costs without provider input; however, because these plans do not contract with hospitals and facilities to provide their members care at in-network rates, their members are finding themselves out-of-network at many hospitals, including UPMC.
Yes. Because we want our patients to have as much information as possible about their access to UPMC care and services, we list the products we have identified as out-of-network on our website. This listing can be found at UPMC.com/OONFAQS.
Please Note: If a plan is not listed, that does not mean that it is in-network. The best way for a member to check provider network status is to ask their plan.
Remember: You need to ask if the UPMC provider is in-network with your plan. Your plan administrator telling you that you can “go to UPMC” is insufficient and might result in your being personally responsible for unpaid out-of-network bills.
UPMC requires payment in advance for out-of-network services. If a patient wishes to schedule out-of-network care — such as same-day surgery or advanced radiology — UPMC will provide them with an estimate of these costs. The total amount due on the estimate will need to be paid in full in order to move forward with services. For most out-of-network physician office visits, UPMC collects a $200 prepayment.
To ensure that you understand your financial responsibilities before scheduling services, you can call a UPMC financial counselor at 800-371-8359 and select Option 5 for Price Estimates. They will be able to give you an estimate for the care you are interested in scheduling.
If the care provided ultimately costs more than the prepayment amount, you will receive a bill in the mail for any additional amounts due. It will be your responsibility to pay the additional amounts in a timely manner, even if those additional services were not planned or were not included in the original estimate you received.
No. UPMC is not able to accept partial payments or arrange a payment plan for prepayment amounts due. Required deposit amounts are due in full and in advance of services.
Yes. Prepayment is not required for the following:
COVID-19 — Care and treatment related to a possible or confirmed case of COVID-19
Emergency Care — All patients, regardless of insurance coverage, or the lack of insurance, who present to any UPMC Emergency Department for care will receive an appropriate medical screening examination and any stabilizing care necessary for their emergent condition.
Pediatric Care – Care and services provided at UPMC Children’s Hospital of Pittsburgh, UPMC Children’s outpatient locations, and UPMC Children’s Community Pediatrics
Even if prepayment is waived, patients who receive out-of-network UPMC care will still be financially responsible for the costs of the out-of-network care they receive and will be balance-billed for any out-of-network amounts owed that their health insurance plan fails to pay.
In some cases, patients may be able to request that their health insurance plan pursue a single-case agreement with UPMC, for a specific scope of care. Patients must initiate this process with their insurer.
It will depend on your specific health plan. Some companies that use unilateral pricing offer plans that are out-of-network for UPMC hospitals but in-network for UPMC physicians in outpatient offices. If your plan does not provide in-network access for office visits, UPMC collects a $200 prepayment for most out-of-network physician office visits.
Balance billing is a medical bill from a health care provider, sent after care has been provided. The amount of the bill is the difference between the total cost of services and the amount the health insurance paid, or the amount that was paid in advance. Even though UPMC collects payment in advance for out-of-network services, based on an estimate, patients may have an account balance following the out-of-network care and will receive a balance bill in the mail.
If you have questions about access to any UPMC doctors, hospitals, or services, please call our help line at 1-855-646-8762.
Updated 10/14/2020
