Beverly Enterprises, Inc. v. Commonwealth
Beverly Enterprises, Inc. v. Commonwealth
Opinion of the Court
Opinion by
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).
The Program provides for cost-related reimbursement to skilled nursing home facilities, such as Mountain-view, 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.
On August 26, 1986, Beverly filed a timely appeal to OHA regarding the audit report for the fiscal period ending June 30, 1983. OHA filed a motion to quash Beverly’s appeal for failure to state the specific issues appealed which was granted by OHA on December 1, 1987. Accordingly, Beverly petitioned this Court for review.
This Court previously established a pragmatic evaluation standard when it suggested that a petition for appeal when read as a whole, could be sufficiently specific to constitute a valid appeal. Eisenberg v. Department of Public Welfare, 86 Pa. Commonwealth Ct. 358, 485 A.2d 511 (1984), affirmed as modified, 512 Pa. 181, 516 A.2d 333 (1986). Additionally, DPW misinterprets this Court’s determination in Mansion Nursing & Convalescent Home, Inc. v. Department of Public Welfare, 96 Pa. Commonwealth Ct. 143, 506 A.2d 533 (1986) which denied a petition for appeal. Mansion is distinguishable because the petitioner failed to mention either specifically or by inference a previous expense as part of its original appeal and, although this was due through no fault of petitioner, the tardily raised issue was denied reconsideration. The instant case, however, relates to a single issue of contention, i.e., a zero-cost determination for Mountain view’s 1983 audited costs. Beverly clearly stated that its appeal was from the audit report pertaining
Accordingly, the order of the Office of Hearings and Appeals is reversed and this case is remanded for a determination on the merits of Beverly’s appeal.
Order
And Now, this 12th day of April, 1989, the order of the Office of Hearings and Appeals is reversed and the case remanded consistent with the foregoing opinion.
Jurisdiction relinquished.
DPW regulations which relate to Medicaid provider appeals state that the appeal request must specify the issues presented for review and that the notice of appeal shall set forth in detail the reasons for appeal.
The issue of the appropriate DPW policies regarding determination of costs for delinquent providers as applied to Beverly will not
Our scope of review from a DPW .determination is limited to determining whether the adjudication is supported by substantial
Reference
- Full Case Name
- Beverly Enterprises, Inc. d/b/a Mountainview Christian Home v. Commonwealth of Pennsylvania, Department of Public Welfare
- Cited By
- 1 case
- Status
- Published