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RENOVO HOSPITAL ASSOCIATION v. COMMONWEALTH PENNSYLVANIA (06/26/84)

decided: June 26, 1984.

RENOVO HOSPITAL ASSOCIATION, T/A BUCKTAIL MEDICAL CENTER, PETITIONER
v.
COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, RESPONDENT



Appeal from the Order of the Department of Public Welfare in the case of Appeal of: Renovo Hospital Association t/a Bucktail Medical Center, File Nos. 23-81-25; 23-81-75; and 23-81-85.

COUNSEL

Jack M. Mumford, with him, Roland Morris, Duane, Morris & Heckscher, for petitioner.

Bruce G. Baron, Assistant Counsel, for respondent.

Judges Williams, Jr., Barry and Palladino, sitting as a panel of three. Opinion by Judge Barry.

Author: Barry

[ 83 Pa. Commw. Page 356]

This appeal arises from an order by the Secretary of the Department of Public Welfare (Secretary) which reversed an order of the Office of Hearings and Appeals. A thorough perusal of the record reveals a complex mixture of facts, events and appeal provisions under the Pennsylvania Code.

The petitioner, Renovo Hospital Association t/a Bucktail Medical Center (Bucktail), is licensed by the Pennsylvania Department of Health as a certified provider of medical services under the Pennsylvania Medical Assistance Program (PMAP). PMAP provides payment for medical services rendered by certified health care providers to persons unable to afford them. The Department of Public Welfare (DPW) funds institutional providers, such as Bucktail, through a two-step process. Providers receive an interim per diem rate for each inpatient day of care rendered by the provider. The interim per diem

[ 83 Pa. Commw. Page 357]

    rate reflects the audited per diem costs to care for medical assistance patients in the prior fiscal year.

When the fiscal year concludes, institutional providers must submit a report which indicates the cost to care for medical assistance patients. The report is audited and reconciled with the interim payments made during the fiscal year. The audit and reconciliation thus consist of the interim settlement and final settlement.

The program covers two levels of nursing services -- intermediate and skilled. A free-standing nursing facility, an intermediate level facility, receives a reimbursement rate from the program less than the rate received by a hospital-based nursing facility (HBNF), a skilled facility. Bucktail received rates consistent with a free-standing nursing facility. At various times, Bucktail requested classification as an HBNF in order to receive the increased reimbursement rates. These requests constitute the heart of this appeal.

On March 5, 1980, March 6, 1980, and May 27, 1980, Bucktail requested HBNF status under the exception criteria in 55 Pa. Code § 9424.6(b), Skilled Nursing Facility Participation Requirements.*fn1 The

[ 83 Pa. Commw. Page 358]

    request was made for the fiscal year July 31, 1979, to June 30, 1980. By letter dated August 15, 1980, the Director of the Bureau of Reimbursement Methods of DPW denied the request because Bucktail did not satisfy the exception criteria to qualify as an HBNF. On August 28, 1980, Bucktail appealed this decision which was docketed as No. 23-81-25 (HBNF denial appeal).

On October 9, 1980, Bucktail requested a reconsideration of its status. On October 26, 1980, the Director denied this request. On November 26, 1980, Bucktail appealed this decision, docketed No. 23-81-75 (HBNF reconsideration denial).

On February 26, 1981, Bucktail received its Tentative Interim Rate Settlement from DPW which advised Bucktail of an overpayment by PMAP. The Comptroller of DPW informed Bucktail that it had

[ 83 Pa. Commw. Page 359]

    thirty days to appeal the interim rate settlement pursuant to 71 P.S. § 1710.41.*fn2 On March 24, 1981, Bucktail appealed the interim rate, docketed No. 23-81-85 (interim rate appeal).

On July 13, 1981, Bucktail received a Final Settlement which indicated that Bucktail had received an overpayment. Bucktail was informed again by the comptroller that it had thirty days to appeal the settlement under 71 P.S. § 1710.41. On July 31, 1981, Bucktail appealed ...


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