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BEVERLY ENTERPRISES v. COMMONWEALTH PENNSYLVANIA (04/12/89)

decided: April 12, 1989.

BEVERLY ENTERPRISES, INC. D/B/A MOUNTAINVIEW CHRISTIAN HOME, 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: Mountainview Christian Home, File Nos. 23-86-101 and 40-86-058.

COUNSEL

Thomas H. Brock, with him, Malcolm J. Harkins, Casson, Harkins & LaPallo, for petitioner.

Bruce G. Baron, Assistant Counsel, for respondent.

Judges Colins and Smith, and Senior Judge Kalish, sitting as a panel of three. Opinion by Judge Smith. Judge MacPhail did not participate in the decision in this case.

Author: Smith

[ 125 Pa. Commw. Page 81]

Petitioner, Beverly Enterprises, Inc., (Beverly) owner of Mountainview Christian Home (Mountainview), appeals an order of the Department of Public Welfare (DPW), Office of Hearings and Appeals (OHA), which denied, for failure to specify issues in dispute, Beverly's appeal of a DPW determination of Mountainview's Medicaid reimbursement. The OHA order is reversed and remanded.

The issue before this Court is whether Beverly's appeal to DPW was sufficiently specific for review as required by 55 Pa. Code §§ 1181.101(d), 1101.84(b)(2).*fn1

[ 125 Pa. Commw. Page 82]

Although this case raises a procedural issue, a preliminary description of DPW's Medicaid reimbursement program (Program) places the procedural dispute in context.

The Program provides for cost-related reimbursement to skilled nursing home facilities, such as Mountainview, for services the facility has furnished to Medicaid beneficiaries. DPW makes interim payments to a facility subject to a year-end settlement based upon a year-end cost report filed by the facility and audited by DPW. Facilities eligible for the Program must submit a cost report to DPW within ninety days of the close of each fiscal year which DPW uses to determine a facility's provider reimbursement status after audit and any necessary adjustments. 55 Pa. Code §§ 1181.64, 1181.74. In addition, if a facility does not timely file a cost report, DPW may terminate the facility's participation in the Medicaid program. 55 Pa. Code § 1181.91. Finally, a facility that enters into an agreement of sale or termination must file a final cost report with DPW within thirty days of said transaction; and if the final cost report is not submitted, DPW will make a settlement for the fiscal year in which sale or termination occurred based upon the last final per diem rate which DPW had audited for said facility. 55 Pa. Code §§ 1181.73(a), 1181.73(b).

The record reveals that on July 1, 1985, Beverly acquired Mountainview as DPW auditors were reviewing Mountainview's reimbursement status for the fiscal period ending June 30, 1983. On July 28, 1986, DPW notified Beverly that no costs could be audited for the fiscal period ending June 30, 1983 because the prior owners, Medwest, had failed to file a cost report for that period. Due to this failure, DPW determined that the facility's audited costs for the period should be set at zero.*fn2 Therefore, DPW demanded that the new owner,

[ 125 Pa. Commw. Page 83]

Beverly, refund all interim payments in the amount of $317,165.58 that DPW made to the prior owner of Mountainview for fiscal period ending June 30, 1983. In reviewing the record, there is an important question of fact in dispute. Petitioner Beverly claims that DPW has demanded a refund from Beverly of interim Medicaid payments made to the previous owner. This claim is supported by a letter from the Comptroller's office demanding the sum of $317,165.58 of DPW overpayment. DPW disagrees, however, stating that "DPW has demanded payment from the prior owner, not from ...


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