Merit Behavioral Care Corp. v. State of Vermont Independent Panel of Mental Health Providers

2004 VT 12, 845 A.2d 359, 176 Vt. 221, 2004 Vt. LEXIS 14
CourtSupreme Court of Vermont
DecidedFebruary 6, 2004
Docket02-271
StatusPublished
Cited by4 cases

This text of 2004 VT 12 (Merit Behavioral Care Corp. v. State of Vermont Independent Panel of Mental Health Providers) is published on Counsel Stack Legal Research, covering Supreme Court of Vermont primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Merit Behavioral Care Corp. v. State of Vermont Independent Panel of Mental Health Providers, 2004 VT 12, 845 A.2d 359, 176 Vt. 221, 2004 Vt. LEXIS 14 (Vt. 2004).

Opinions

Dooley, J.

¶ 1. Merit Behavioral Care Corporation, a review agent that contracted with the State during the relevant time period to provide mental health care benefits to state employees, appeals the superior court’s summary judgment order dismissing its complaint seeking to overturn an independent panel’s decision that Merit should have provided coverage for state employee Jane Doe’s mental health treatment at the Austen Riggs Center. Merit contends that the superior court erred in concluding that (1) Merit had a statutory obligation to provide prospective or concurrent review of Jane Doe’s treatment at Austen Riggs, and (2) Merit had waived the right to deny medical coverage for Doe by failing to provide the required concurrent or prospective review. Merit also argues that the court erred in dismissing, without explanation, its breach-of-contract and indemnity claims against Austen Riggs. We affirm the superior court’s grant of summary judgment to the State, but reverse the court’s summary judgment ruling in favor of Austen Riggs and remand the matter for the court to consider, in the first instance, Merit’s claims against Austen Riggs.

¶ 2. The State contracted with Merit to provide mental health care benefits to state employees under the State’s medical benefit plan. By providing these benefits, Merit functioned as a “review agent” under 8 V.S.A. § 4089a(b)(4), thereby subjecting itself to the statutory requirements set forth in § 4089a. For its part, Merit contracted with Austen Riggs, a mental health care facility, to be one of its mental health care service providers under the State plan. Austen Riggs specialized in the care of seriously ill, treatment-resistant patients. Under its contract with Merit, Austen Riggs agreed not to seek compensation directly from a covered member for covered services, and to “cooperate actively” with [223]*223Merit’s ease management procedures, quality assurance protocols, and precertification and concurrent review procedures and policies. Austen Riggs also agreed to indemnify Merit “from and against any losses and expenses whatsoever arising from and to the extent attributable to any errors or omissions” by it in the provision of services under the agreement.

¶ 3. Jane Doe, a state employee covered under the State’s plan, was referred to Austen Riggs in April 1997 for treatment of a long-term mental disorder. Doe was in the midst of a major depressive episode of the illness, which had proven to be resistant to various attempts at treatment over the years. After Doe’s initial admission to Austen Riggs, a dispute arose between Merit and Austen Riggs over Doe’s treatment plan. The conflict centered around inconsistencies between, on the one side, Austen Riggs’ policy of having patients stay a minimum of thirty days at its Center once they were found to be appropriate candidates for treatment there, and, on the other side, Merit’s policy of requiring daily review to ensure that continued residential mental health care services are medically necessary.

¶ 4. Shortly after Doe was admitted to Austen Riggs, Merit’s medical director informed it that he could not conduct concurrent review of Doe’s treatment because Austen Riggs’ treatment plan did not fit Merit’s method of managing in-patient treatment. The director noted that Austen Riggs did not share Merit’s assumptions that “each day needed to be reviewed and a patient should be discharged or at least stepped down to a lesser level of care as soon as clinically indicated.” Merit claimed that it had been misled about Austen Riggs’ “willingness to work with our system of review and length of stay for admitted patients,” while Austen Riggs countered that Merit knew of its policies, including its minimum-stay policy, when Merit contracted with it to be one of Merit’s mental health care providers. In the end, Merit informed Austen Riggs that it would approve Doe’s initial six-day stay and consider her claim for further treatment after retrospective review of her medical record.

¶ 5. Several days later, Merit informed Doe that it had authorized payment for her initial stay at Austen Riggs, but that “[bjecause of differences between us and Austen Riggs regarding our standards for utilization review, we have pended the remainder of your stay.” The gist of the letter was that Merit would determine the medical necessity of Doe’s treatment after her discharge. Austen Riggs also sent Doe a letter stating that because Merit had declined its request “for further approval of medical necessity,” she would have to pay for treatment herself if she [224]*224decided to stay at Austen Riggs. She agreed to do so, and remained at Austen Riggs for the next several months.

¶ 6. In December 1997, Doe sought reimbursement from Merit for her treatment at Austen Riggs. Merit denied Doe’s claim because the available documentation did not support “the medical necessity of this level of care.” Doe filed an additional claim for reimbursement in March 1998, which Merit also denied. Merit explained that the medical records submitted by Austen Riggs indicated that Doe’s treatment failed to meet Merit’s utilization management guidelines, and that there were no unique or special circumstances to justify departure from those guidelines.

¶ 7. In April 1999, Doe appealed to the Independent Panel of Mental Health Care Providers, a statutory body established to promptly consider adverse decisions made by review agents. See 8 V.S.A § 4089a(c)(7). Following a hearing, the independent panel concluded that Doe’s treatment at Austen Riggs was medically necessary and therefore covered under the State’s plan. The panel found that Doe was in acute need of treatment because of her complete dysfunction and recent suicide attempts. The panel also found that long-term treatment at Austen Riggs was appropriate because Doe had previously failed to benefit from other treatment modalities, including short-term hospitalization, residential/day treatment, aggressive medication therapy, cognitive-behavioral therapy, and electroconvulsive treatment.

¶ 8. Merit sought review of the independent panel’s decision in the superior court pursuant to Y.R.C.P. 75, and added breach-of-contract and indemnity claims against Austen Riggs. The State, representing the panel, moved to dismiss Merit’s complaint, and Merit cross-moved for judgment on the pleadings. The superior court denied the motions, but later granted summary judgment to both the State and Austen Riggs on-the parties’ cross-motions for summary judgment. The court concluded that as a “review agent,” Merit was obligated to engage in “service review,” which must be “prospective or concurrent with the [patient’s] treatment.” See 8 V.S.A. § 4089a(b)(4)-(5), (c)(5). Because the statute does not provide a specific remedy for a review agent’s failure to conduct a concurrent or prospective review, the court analogized to insurance law. Drawing on Reynolds v. John Hancock Life Insurance Co., 117 Vt. 541, 548, 97 A.2d 121, 126 (1953), the court concluded that Merit had a statutory duty to “speak” and make a coverage decision prospectively or concurrently with Doe’s treatment. According to the court, by failing to make a decision, Merit waived any objections to Doe’s request for coverage. The court also granted summary judgment to Austen Riggs [225]*225without discussing Merit’s breach-of-contract and indemnity claims. This appeal followed the court’s denial of Merit’s motion to alter the judgment.

¶ 9. We review a grant of summary judgment using the same standard as the trial court.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
2004 VT 12, 845 A.2d 359, 176 Vt. 221, 2004 Vt. LEXIS 14, Counsel Stack Legal Research, https://law.counselstack.com/opinion/merit-behavioral-care-corp-v-state-of-vermont-independent-panel-of-mental-vt-2004.