The saga continues between UPMC hospitals and Highmark.
UPMC reported revenue of $5.1 billion in the quarter ending March 31, 2019, up 10 percent from the $4.6 billion reported in the first quarter of last year. At the same time, expenses rose by more than 11 percent. Since revenues are still larger than expenses for UPMC, this resulted in reported net income of $289 million, an increase over the $97 million reported for the first quarter of 2018.
Enrollment in UPMC health plans is up to 3.5 million members as of March 31, up 3 percent compared to the first three months of 2018.
So, what does all this mean?
Did the 3 percent increase drive a 10 percent increase in revenue, and does this mean they are winning their enrollment battle with Highmark? It is much more complicated than that. We also should consider that new accounting rules impact the reporting of revenue between these periods.
I think the fact that UPMC Medicare Advantage (MA) enrollment is up almost 8 percent for the month of April 2019 over the month ending April 2018, based on Centers for Medicare & Medicaid Services (CMS) data, is a solid sign that UPMC is, in fact, winning.
Here are the Medicare Advantage enrollment totals for UPMC’s Medicare Advantage products in April of 2018 and 2019:
Medicare Advantage members generate larger premiums in terms of per-member, per-month revenue than other insurance products. They also are much more costly than the average plan, through which members may or may not use any services in a given period.
Having worked with MA plans, there is a general rule of thumb.
The first three months, as premiums come in, you have parties and celebrate. The second three months, as claims start to hit, you start doing projections. The third quarter, as you see claim payments start to meet premiums, you sober up. The last quarter, if claim payments overwhelm premiums, you start reaching out to old friends through LinkedIn.
In addition to claim payments, MA plans must work through “risk adjustment,” both quarterly and annually. Medicare pays MA plans a base amount per member that is adjusted based on their Hierarchical Condition Category, or HCC, scoring. That means they start out with a “per-member, per-month” figure that shifts as claims data are filed and each member’s risk score is adjusted.
UPMC, along with other MA plan providers, make sure they have systems to monitor risk scores and control costs as they grow.
With health systems becoming insurance plans and plans buying providers, one thing is for sure. Data, infrastructure, and the will to manage based on that data will determine winners and losers.
Programming Note:
Listen to Tim Powell today and every Tuesday on Talk Ten Tuesday, 10-10:30 a.m. ET
In an ideal world, every diagnosis code you submit to the Centers for Medicare & Medicaid Services (CMS) would be backed by bulletproof documentation –
The Centers for Medicare & Medicaid Services (CMS) recently published a concise “Hospice Fast Facts,” which provides key insights into hospice utilization in the 2024
Please log in to your account to comment on this article.
Sepsis remains one of the most frequently denied and contested diagnoses, creating costly revenue loss and compliance risks. In this webcast, Angela Comfort, DBA, MBA, RHIA, CDIP, CCS, CCS-P, provides practical, real-world strategies to align documentation with coding guidelines, reconcile Sepsis-2 and Sepsis-3 definitions, and apply compliant queries. You’ll learn how to identify and address documentation gaps, strengthen provider engagement, and defend diagnoses against payer scrutiny—equipping you to protect reimbursement, improve SOI/ROM capture, and reduce audit vulnerability in this high-risk area.
Only ICD10monitor delivers what you need: updates on must-know changes associated with the FY26 IPPS, including new ICD-10-CM/PCS codes, CCs/MCCs, and MS-DRGs, plus insights, analysis and answers to your questions from two of the country’s most respected subject matter experts.
This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.
During this essential RACmonitor webcast Michael Calahan, PA, MBA Certified Compliance Officer, will clarify the rules, dispel common misconceptions, and equip you with practical strategies to code, document, and bill high-risk split/shared, incident-to & critical care E/M services with confidence. Don’t let audit risks or revenue losses catch your organization off guard — learn exactly what federal auditors are looking for and how to ensure your documentation and reporting stand up to scrutiny.
Learn how to navigate the proposed elimination of the Inpatient-Only list. Gain strategies to assess admission status, avoid denials, protect compliance, and address impacts across Medicare and non-Medicare payors. Essential insights for hospitals.
RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.
Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
