Brooklyn Park-based PrairieCare dropped out of Medica's provider network Tuesday, claiming the insurer limits mental health care for children and teens without justification and beyond the norm at other health plans.
Medica shot back, saying that PrairieCare is the outlier, with its patients staying longer at the hospital and requiring readmission at higher rates than those treated by other health care providers.
The bottom line: Medica subscribers won't have access to PrairieCare facilities at in-network prices.
"I mainly worry about parents whose kids are in an emergency situation having higher out-of-pocket costs, and not knowing that's the case," said Sue Abderholden, executive director of the National Alliance of Mental Illness in Minnesota. She added that she could not comment on the arguments put forward by both sides.
PrairieCare, a private company that employs about 400 people, has six locations in the Twin Cities metro area and one in Rochester. Owned by two child psychiatrists, the mental health provider does not release financial information.
Medica is one of the state's largest health insurers, with about $125 million in operating income on $3.5 billion in revenue during 2014. It employs about 1,300 people.
The contract dispute went public in September after PrairieCare sent letters to patients notifying them of the potential change in its network status. Last year, about 360 children and adolescents with Medica coverage obtained inpatient and partial-inpatient care at PrairieCare.
In the near term, PrairieCare will continue to serve admitted Medica patients under the in-network contract until they complete treatment, said Tom Lehman, government relations manager for PrairieCare. There were six Medica patients receiving inpatient care Monday, Lehman said, and "numerous" health plan patients receiving partial hospitalization care, where patients participate in a full day of mental health treatment, including academic instruction, but go home each night.
"It became clear yesterday morning that Medica is unable or unwilling to reach an agreement with PrairieCare," Lehman said in a statement Tuesday. "Consequently, PrairieCare has left Medica's network for both inpatient hospital services as well as partial hospitalization program (PHP) services."
He added: "Medica continued to insist on drastically short treatment times that are outside the norms for other health plans in Minnesota."
In a statement, Medica said its network of providers still includes "full-capability systems" such as Allina and Fairview that will meet the treatment needs of subscribers. When needed, Medica will make out-of-network exceptions for PrairieCare services, said Glenn Andis, a senior vice president at the health insurance company.
"Contrary to PrairieCare's assertions, our disagreement is rooted in our commitment to ensuring our patients get quality, individualized, recovery-focused care," Andis said in a statement. "PrairieCare is a significant outlier in terms of length of hospital stays, and its hospital readmission rate for children, a recognized measure of quality, is three times higher … than providers of similar services."
Medica says it wanted PrairieCare to work with the insurer on treatment reviews and discharge planning that would help children transition to community-based services that are less restrictive, and lead to better outcomes.
But Lehman argued that Medica has sought extreme limits on treatment times, and suggested a financial motive could be at play.
"We don't want to provide unethical care, and that's what we feel is happening when Medica pushes a shorter length of stay," said Jen Holper, the community relations supervisor for PrairieCare.
Christopher Snowbeck • 612-673-4744
Twitter: @chrissnowbeck
