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WINDBER HOSPITAL v. COMMONWEALTH PENNSYLVANIA (08/05/88)

decided: August 5, 1988.

WINDBER HOSPITAL, WHEELING CLINIC, PETITIONER
v.
COMMONWEALTH OF PENNSYLVANIA, DEPARTMENT OF PUBLIC WELFARE, RESPONDENT



Appeal No. 3382 C.D. 1986, from the Order of the Department of Public Welfare in the case of Appeal of Robert A. Chrzan, Executive Director, Windber Hospital, Wheeling Clinic, dated October 23, 1986.

COUNSEL

Jeffrey L. Berkey, Fike, Cascio & Boose, for petitioner.

Jason W. Manne, Assistant Counsel, for respondent.

Judges Craig and Doyle, and Senior Judge Kalish, sitting as a panel of three. Opinion by Judge Doyle.

Author: Doyle

[ 118 Pa. Commw. Page 420]

This is an appeal by Windber Hospital, Wheeling Clinic (Windber) from an order of the Department of Public Welfare's (DPW's) Office of Hearings and Appeals to deny payment for certain hospitalization costs to Windber.

The facts indicate that one B.J. was admitted to Windber Hospital on December 29, 1985 suffering from a myocardial infarction and discharged on January 8, 1986. She was readmitted on January 12, 1986, at which time she was suffering from a second myocardial infarction. The hearing officer determined that although the second admission was medically necessary, and although the patient was treated properly on both occasions and hospitalized for the appropriate length of time, payment for the second hospitalization must be denied because the readmission occurred within seven days of the discharge and was based upon "complications/medical condition which related to the first admission."

[ 118 Pa. Commw. Page 421]

The relevant DPW regulation reads as follows:

Payment policy for readmissions.

(a) Except as specified in subsection (c), if a recipient is readmitted to a hospital within seven days of discharge, the Department makes no payments in addition to the hospital's original DRG [diagnosis related group] payment. If the combined hospital stay qualifies as an outlier under ยง 1163.56 (relating to outliers) an outlier payment will be made.

(b) If a patient is readmitted within 7 days of discharge for the treatment of conditions that could or should have been treated during the previous admission, the Department makes no payment in addition to the hospital's original DRG payment.

(c) Except as specified in subsection (b), if a patient is readmitted to the hospital due to complications of the original diagnosis and this results in a different DRG with a higher payment rate, the Department pays the ...


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