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had a responsibility to ensure that Mr. Plocica was being treated appropriately at the correct level of care, and that his discharge from the hospital on July 8, 1998 was appropriate As Ms. McDaniel testified in her deposition of October 1, 1999, her understanding of her job responsibility as a Merit/Magellan nurse care manager was “[to] make sure that patients were getting the appropriate kind of treatment that they needed for what their problems were, and that they were getting quality care.” Mr. Plocica’s inpatient treatment was authorized by care manager McDaniel from June 26 to July 4, 1998 in accordance with Merit’s 1997-1998 Utilization Management Guidelines. Additional authorized days beyond July 4 would require a telephonic peer-to-peer review with Dr. Eudaly and Dr. Neller that was scheduled on July 6, 1998. |
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There are substantive differences of recollection by Drs. Neller and Eudaly in deposition testimony about the content of their July 6 peer-to-peer review discussion, It apparently was common practice for Merit/Magellan to conduct retroactive and concurrent utilization reviews simultaneously in a peer-to-peer review (an example of this would be the July 6 peer-to-peer review in which Dr. Neller authorized retroactively July 4 and 5 and authorized concurrently July 6 and July 7). In the peer-to-peer review on July 6, 1998, Dr. Eudaly requested several additional days of inpatient treatment for Mr. Plocica. This request appears to have been appropriate and clearly indicated on the basis of Mr. Plocica’s clinical status on July 6, 1998. Dr. Neller refused to authorize more days beyond July 7, 1998, thereby authorizing only one (1) additional inpatient day. |
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Dr. Neller memorialized the July 6 peer-to-peer review on a Merit Behavioral Health Care Physician Advisor Review Form documenting that Dr. Eudaly agreed with the determination to authorize only one additional day. He wrote, “[Dr. Eudaly] wanted more time but agreed with another peer [review].” However, he also checked off “Yes” in a box on the form that reads “If adverse determination, informed attending of appeal process.” Why Dr. Neller, who consistently argued in his deposition testimony that an appeal was never triggered, would have notated that on the Review Form is unclear. In fact Merit/Magellan’s care manager Joan McDaniel and Merit/Magellan’s Medical Director Roger Kobes testified that there was nothing to appeal. If there was no adverse determination, why did Dr. Neller have to inform Dr. Eudaly of the appeal process? There appear to be inconsistencies in Dr. Neller’s testimony about the substance of his telephone conversation with Eudaly, what he actually documented on the Review Form, and Dr. Eudaly’s testimony that he was never advised of any option to appeal. |
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In addition to his refusal of Dr. Eudaly’s July 6 request for more hospital days, Dr. Neller also failed to offer to place Mr. Plocica on an Individual Case Management (ICM) status. ICM would have made available to Mr. Plocica extra-contractual benefits (such as 24-hour skilled nursing home or residential treatment services). Dr. Neller failed to inform Dr. Eudaly of this option in spite of Dr. Eudaly’s and the Plocica family’s request for such services. The ICM option is documented in the October 1998 Magellan |
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