PETITION FOR REVIEW, (DEPARTMENT OF PUBLIC WELFARE).
R. Mark Faulkner, with him, Michael E. Koll, McQuaide, Blasko, Schwartz, Fleming & Faulkner, State College, for petitioner.
Mary Frances Grabowski, Asst. Counsel, for respondent.
Colins and Smith, JJ., and Barbieri, Senior Judge.
[ 129 Pa. Commw. Page 214]
Milton S. Hershey Medical Center of the Pennsylvania State University (Hershey) appeals from an order of the Secretary of the Department of Public Welfare (DPW) denying reimbursement of costs under Pennsylvania's medical assistance program, 62 P.S. §§ 201-488.*fn1 The issue before this Court is whether DPW's decision to deny Hershey
[ 129 Pa. Commw. Page 215]
reimbursement for sixty days of inpatient medical services was supported by substantial evidence.*fn2
Jennifer Kreiser was admitted to the pediatric intensive-care unit at Hershey on May 3, 1986 with a diagnosis of Leighs Syndrome. Subsequent examination revealed that this child had bleeding in her brain stem secondary to Leighs Syndrome. Upon admission, Jennifer was intubated and placed on mechanical ventilation and several weeks later a gastrostomy tube was inserted and a tracheotomy performed. Within one month of admission, Jennifer's physicians concluded that she was in the terminal stage of Leighs Syndrome and "would continue a downward course with periods of stability on supportive therapy." (Petitioner's Exhibit C-4). Jennifer remained in Hershey's intensive care unit until December 9, 1986, at which time she was transferred to Hummelstown Child Care Center (Hummelstown). Jennifer died in February of 1987.
Effective July 1, 1984, DPW implemented a diagnosis specific payment system for inpatient hospital services which provides for a predetermined specific rate for each medical assistance recipient discharged from care. This predetermined rate is considered payment in full for the services rendered to the discharged recipient. 55 Pa.Code § 1163.51(f). In recognition of those cases in which care is required in excess of what DPW has determined to be average, 55 Pa.Code § 1163.56 permits additional reimbursement for "outlier" days, defined as "an inpatient hospital case having either an extremely long length of stay or extraordinarily high costs in comparison to most discharges for the same diagnosis related group (DRG)." 55 Pa.Code § 1163.2.
Hershey requested that DPW certify or authorize payment for 190 outlier days of treatment for Jennifer; however, DPW refused certification for treatment between October
[ 129 Pa. Commw. Page 21610]
, 1986 and December 9, 1986. DPW argues that this result is mandated by 55 Pa.Code § 1163.59(c)(3) which provides that certain days ...