Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Official citation and/or docket number and footnotes (if any) for this case available with purchase.

Learn more about what you receive with purchase of this case.



decided : January 30, 1989.




Mark H. Gallant, Esq., Jeffrey B. Schwartz, Esq., Gerald Gornish, Esq., Philadelphia, Pa., for PETITIONER

John Kane, CHIEF COUNSEL, Cynthia White Williams, Esq., ASST. COUNSEL, Harrisburg, Pa., for RESPONDENT

Before: Honorable Joseph T. Doyle, Judge, Honorable Doris A. Smith, Judge, Honorable Jacob Kalish, Senior Judge

Author: Kalish


Presbyterian-University of Pennsylvania Medical Center (Presbyterian) petitions for review from an order of the Department of Public Welfare (DPW), which denied Presbyterian's appeal from the prospective payment rates established by DPW.

DPW issued prospective payment rates pursuant to a new payment system for in-patient hospital services furnished to medical assistance recipients. Presbyterian appealed the payment rates established by DPW. DPW's Office of Hearings and Appeals denied relief, and Presbyterian now appeals to this court. DPW's examiner found that the prospective systems*fn1 of reimbursement, set by DPW and based on the Diagnosis Related Group (DRG), are substantially price-fixing systems. Further, a hospital's actual costs incurred in caring for medical assistance patients covered by DRG rates have no bearing on the payment the hospital will receive for that care. The examiner recognized that the change from a cost-based reimbursement to prospective payment was a fundamental restructuring of the payment system.*fn2 In addition, the examiner's findings noted that Presbyterian is an efficiently and economically operated hospital, and the prospective payment rate set by DPW resulted in the hospital being paid approximately $1,086,871 less than its costs. The examiner found that Presbyterian provides $3,000,000 a year in free care, and experiences a bad debt situation. The examiner concluded that the prospective payment rate was not reasonable and adequate, and that DPW made numerous errors in calculation of the rate. The examiner's recommendations were not adopted by the Office of Hearings and Appeals, which approved DPW's rate schedule.

Presbyterian contends that DPW, in fixing the prospective rate, failed to take into account the fact that the hospital served a disproportionate number of low-income patients with special needs. Presbyterian asserts that this is a violation of section 443.1(1) of the Public Welfare Code, Act of June 13, 1967, P.L. 31, as amended, 62 P.S. § 443.1(1), which provides for the payment of reasonable costs of in-patient hospital care.

Our scope of review is limited to determining whether the adjudication is supported by substantial evidence, whether the petitioner's constitutional rights have been violated and whether an error of law has been committed. Estate of McGovern v. State Employees' Retirement Board, 512 Pa. 377, 517 A.2d 532 (1986).

Pursuant to section 1163.52 of the Medical Assistance Manual, 55 Pa. Code § 163.52, which deals with the prospective payment methodology, DPW bases payment for in-patient hospital services on the classification of in-patient hospital discharges in the DRG classification. Hospitals are classified into specific groups. DPW first determines each hospital's concept score based on each of the four following concepts:

(1) teaching status

(2) medical assistance volume

(3) environmental characteristics

(4) hospital costs.

Section 1163.121(a), 55 Pa. Code § 1163.121(a). In addition, the hospital is reimbursed for such things as building and fixture depreciation, medical education and physician services.

Although section 443.1 of the Public Welfare Code provides for the payment of the reasonable cost of in-patient care, the federal government changed the reasonable cost concept to one of reimbursement for costs of an efficiently and economically operated hospital when it amended its regulations to adopt the DRG system. 42 U.S.C. 1396a(a)(13)(A).

DPW is not required to pay all of the reasonable costs. The DRG system is designed to safeguard against unnecessary utilization and to assure that payments are consistent with efficiency, economy and quality care. To reimburse for all costs would defeat the purpose of the DRG system. Mississippi Hospital Association. Inc. v. Heckler, 701 F.2d 511 (5th Cir. 1983). Review is limited to statewide average rates for all hospitals.

While the hospital did have a disproportionate number of low-income patients, that factor was considered in fixing the grouping system. Two of the concepts include environmental characteristics and medical assistance volume which are sensitive to this issue.

The record does show that DPW did err in its calculation of rates effective July 1, 1984, which is not controverted. The examiner found, and the spokesman for DPW, David Feinberg, agreed that there were some errors in the method of calculation, particularly in the area of double counting, dividing too large a number of cases into the total pool of money available, and the length-of-stay data. However, the examiner found that these errors were insignificant and in fact, in some instances, benefited the hospital. The examiner further found that the source of the inaccuracies were to a great extent hospital-produced. A review of the record discloses that these findings are based on substantial evidence.

Accordingly, we affirm.


NOW, January 30, 1989, the decision of the Department of Public Welfare, at docket numbers 37-84-102 and 37-85-012, is affirmed.

Buy This Entire Record For $7.95

Official citation and/or docket number and footnotes (if any) for this case available with purchase.

Learn more about what you receive with purchase of this case.