TITLE 67 Pa.C.S.A. PUBLIC WELFARE

Transcription

1 TITLE 67 Pa.C.S.A. PUBLIC WELFARE Pennsylvania legislation has been partially consolidated and codified as part of the program initiated by Act 1970, Nov. 25, P.L. 707, No Consequently, statutory sections are designated as either Pa.C.S.A. (Purdon's Pennsylvania Consolidated Statutes Annotated) under numbers assigned legislatively, or P.S. (Purdon's Pennsylvania Statutes Annotated) under numbers assigned by the publisher. Chapter 1. PRELIMINARY PROVISIONS 11. MEDICAL ASSISTANCE HEARINGS AND APPEALS Section Definitions. CHAPTER 1 PRELIMINARY PROVISIONS Historical and Statutory Notes Prior Laws: P.L. 1063, No. 271; and repealed by 1981, A prior Chapter 1 entitled "General Oct. 22, P.L. 317, No. 111, 1. Provisions" was added by 1972, Nov. 15, 101. Definitions The following words and phrases when used in this 1 chapter shall have the meanings given to them ih this section unless the context clearly indicates otherwise: "Department" The Department of Public Welfare of the Commonwealth. "Secretary." The Secretary of the Department of Public Welfare of this Commonwealth. "the" in enrolled bill. Historical and Statutory Notes. Prior Laws: No. 271, 101; and repealed by 1981, A prior 101, containing definitions, was derived from 1972, Nov. 15, P.L. 1063, Oct. 22, P.L. 317, No. 111, 1. CHAPTER 11 MEDICAL ASSISTANCE HEARINGS AND APPEALS Section Section Definitions Determinations, review, appeal and Hearings before the bureau. enforcement Supersedeas Regulations Subpoenas. 103

2 67 Pa.C.S.A PUBLIC WELFARE Definitions The following words and phrases when used in this chapter shall have the meanings given to them in this section unless the context clearly indicates otherwise: "Bureau." The Bureau of Hearings and Appeals of the Department of Public Welfare. "Hearing." A. proceeding commenced in accordance with this chapter by a provider concerning an adjudication of the department relating to the administration of the program. The term includes an action relating to a provider's enrollment in, participation in, claims for payment or damages under or penalties imposed under the program. "Program." The medical assistance program established by subarticle (f) of Article IV of the act of June 13, 1967 (P.L. 31, No.- 21), 1- known as the Public Welfare Code. "Provider." A person that is approved or was approved by the department to participate in the program or that seeks approval to provide medical assistance services under the program. 2002, Dec. 3, P.L. 1147, No..142, 20.1, imd. effective. 162 P.S et seq Hearings before"the bureau (a) General rule. A provider that is aggrieved by a decision of the department regarding the program may request a hearing before the bureau in accordance with this chapter. (b) Filing. (1) Except as provided in paragraph (2), a provider must file a request for a hearing with the bureau in accordance with all of the following: (i) The request must be in writing. (ii) The request must be filed with the bureau: (A) within 30 days of the date of the notice of the departmental action; or (B) if notice was given by mail, within 33 days of the date of the notice of the departmental action. (iii) If the request was filed by first-class mail, the United States postmark appearing upon the envelope in which the request was mailed shall be considered the filing date. The filing date of a request filed in any other manner or bearing a postmark other than a United States postmark shall be the date on which the request is received in the bureau. (2) Paragraph (1) does not apply in the following cases: (i) In a num pro tune hearing under subsection (c). (ii) To the extent set forth in the standing order of the bureau issued under subsection (g).. (iii) To the extent modified by regulations promulgated under section 1106 (relating to regulations). (c) Hearings nunc pro tunc. The bureau, upon written request and for good cause shown, may grant leave for the filing of requests for hearing nunc pro tune pursuant to the common law standards applicable in analogous eases in courts of original jurisdiction. 104

3 PUBLIC WELFARE 67 Pa.C.S.A (d) Amendment. A request for a hearing may be amended as of right within 90 days after the date of filing of the request. (e) Adjudication. (1) The bureau shall hold hearings and conduct adjudications regarding timely filed requests for hearing in accordance with 2 Pa.C.S. Ch. 6 Subch. A (relating to practice and procedure of Commonwealth agencies). (2) Notwithstanding paragraph (1), in holding hearings and conducting adjudications, the bureau shall do all of the following: (i) Act independently of employees or public officials of the department whose actions are subject to review before the bureau. (ii) Not engage in ex parte communications concerning a hearing with any party to the hearing. (iii) Promptly adjudicate timely filed requests for hearing. (iv) Establish deadlines for interim and final actions by the bureau and parties to any proceeding before the bureau. (v) Allow reasonable and necessary discovery in the form of interrogatories, requests for the production of documents, expert reports, requests for admissions and depositions of witnesses and designees of parties, subject to case management plans and limitations as necessary to facilitate the prompt and efficient issuance of adjudications. (vi) Consider and, when appropriate, grant applications by affected parties to consolidate hearings involving substantially similar or materially related issues of law or fact. (vii) Conduct de novo review of all factual and legal issues raised by a provider in the request for hearing based upon evidence presented.to the bureau. (viii) Except as prohibited by statute or regulation, index and publish at reasonable costs determinations issued by the bureau and final orders issued by the secretary adjudicating requests on or after the effective date of this section. By July 1, 2003, the bureau shall make the determinations, final orders and index available electronically without cost to the public. (f) Mediation. The bureau may establish programs and procedures to promote the settlement of matters subject to its jurisdiction or to narrow issues subject to dispute through the use of mediation and arbitration. (g) Standing order. By July 1, 2003, the bureau shall, after receiving comment by interested parties, issue a standing order establishing rules governing practice before the bureau. The standing order shall be published in. the Pennsylvania Bulletin. The standing order of the bureau shall be effective until modified by regulation. 2002, Dec. 3, P.L. 114'7, No. 142, 20.1, imd. effective. 12 Pa.C.S.A. 501 et seq. Standing Order A Standing Order establishing rules governing Medical Assistance provider appeals was issued by the Department of Public Historical and Statutory Notes Welfare, Bureau of Hearings and Appeals in Pa.B. Doc. No , filed for public inspection June 27, 2002, effective July 1, 2003, 33 Pa.B Notes of Decisions - Construction and application Yi Records and documents 1 Notice 3 105

4 67 Pa.C.S.A PUBLIC WELFARE Remand 2 donstruction and application Procedural rule issued by Department of Public Welfare which requires a notice of adjudication to include the date the notice was deposited in the mail or otherwise served on the provider does not specify that the mailing date must be designated as such. Julia Ribaudo Senior Services v. Department of Public Welfare, 2009 WL , Sup Records and documents Nursing home violated standing practice _order (SPO) of Department of Public Welfare when it failed to attach to its position paper, or at least fully identify, documents on which it would rely in appeal of Department audit that disallowed certain costs for reimbursement under a medical assistance program, which was grounds for dismissal of appeal, even though nursing home Claimed the Department already had possession of all the documents and it was overly burdensome to attach all the documents to its position paper. Snyder Memorial Health Center v. Department of Public Welfare, 898 A.2d 1227, Cmwlth Health Remand Commonwealth Court would remand nursing home's challenge to Department of Public Welfare audit, that disallowed reimbursement of certain costs under a medical assistance program, to the Department's Bureau of Hearing and Appeals, for consideration of whether to grant nursing home's motion to amend its.position paper and attach required expert reports, given that Department was not alleging that failure to include the expert reports was a reason to dismiss the challenge. Snyder Memorial Health Center v. Department of Public Welfare, 898 A.2d 1227, Cmwlth Health Notice Department of Public Welfare's notice of adjudication sufficiently advised provider enrolled in Department's Medical Assistance Program of the date of the notice of the action to trigger the 33-day period for administrative appeal of Department audit, even though notice did not specifically des- ignate the date stamped on the notice as the notice's mailing date, and thus provider's appeal from audit report, which was not filed within 33 days of the date of the notice, was untimely, where Department's letter advised provider that if it disagreed with the findings contained in the audit report, it had the right to appeal by filing a written request for a hearing within 33 days of tbe date of the letter, and the letter was date-stamped. Julia Ribaudo Senior. Services v. Department of Public Welfare, 2009 WL , Sup The date of notice of departmental action, for pinposes of triggering 33-day period for administrative appeal of Department of Public Welfare audit, was the date stamped on the notice. Julia Ribaudo Senior Services v. Department of Public Welfare, 2009 WL , Sup Appeal period under statute governing hearings before the Bnieau of Hearings and Appeals of the Department of Public Welfare is triggered by the date of the notice of the departmental action. Julia Ribaudo Senior Services v. Department of Public Welfare, 2009 WL , Sup Accountant at law firm that represented provider, which was enrolled in state Department of Public Welfare's Medical Assistance Program, was not provider's agent, and thus personal service on provider was not effected when accountant acquired audit report from Department, and period in which to appeal audit report did not begin to rim; provider employed accountant only to prepare rate projections, and annual report was given to accountant in preparing projection reports. Julia Ribaudo Senior Services v. Department of Public Welfare, 915 A.2d 700, Cmwith. 2007, reargument denied, appeal granted 946 A.2d 638. Health =. 511 Notice that was mailed by state Department of Public Welfare to provider, which was enrolled in Department's Medical Assistance Program, concerning audit report did not serve to begin appeal period regarding audit report; notice did not set forth mailing date. Julia Ribaudo Senior Services v. Department of Public Welfare, 915 A.2d 700, Cmw1th.2007, reargument denied, appeal granted 946 A.2d 638. Health cz;', 511,1103. Supersedeas (a) Not automatic. A request for hearing filed pursuant to this chapter shall not act as an automatic supersedeas. The bureau may, however, grant a supersedeas upon good cause shown. 106

5 PUBLIC WELFARE 67 Pa.C.S.A (b) Criteria. The bureau, in granting or denying a supersedeas, shall be guided by relevant judicial precedent. Among the factors to be considered are: (1) irreparable harm to the petitioner; (2) likelihood of the petitioner prevailing on the merits; and (3) likelihood of injury to the public or other parties. (c) Prohibition. A supersedeas shall not be issued if injury to the public health, safety or welfare exists or is threatened during the period when the supersedeas would be in effect. (d) Conditions. In granting a supersedeas, the bureau may impose conditions which are warranted by the circumstances, including the filing of a bond or other security Subpoenas Consistent with section 1102(e)(2)(v) (relating to hearings before the bureau), the bureau may issue subpoenas compelling the attendance of witnesses, records and papers. The bureau may enforce its subpoenas in Commonwealth Court. Commonwealth Court, after a hearing, may make an adjudication of contempt or may issue another appropriate order Determinations, review, appeal and enforeement (a) Deterrninations. The bureau shall issue a determination adjudicating contested issues of fact and law and any appropriate order, decree or decision. A determination not appealed in accordance with subsection (b) shall be the final determination of the bureau and shall be binding upon the department and the provider who brought the appeal. (b) Review. (1) A party that is aggrieved by a determination of the bureau may request review of the determination by the secretary within 30 days of the issuance of the determination. (2) If the secretary fails to act upon a request within 30 days of receipt of the request for review, the request for review shall be deemed denied. (3) If the secretary grants review, the secretary shall enter a final order within 180 days of the date of the order granting review. The secretary may affirm, reverse or modify the determination of the bureau or may waive compliance with program requirements to promote fairness and the proper administration of the program. (4) If the secretary grants review but fails to act within 180 days of the date of the order granting the review, the determination of the bureau: shall be deemed approved by the secretary. (c) Appeals. A provider aggrieved by a final determination of the bureau or a final order of the secretary may petition for judicial review in accordance with 2 Pa.C.S. Ch. 7 Subch. Al (relating to judicial review of Commonwealth agency action). (d) Enforcement. Final determinations, orders, decrees or decisions of the department, the bureau or the secretary shall be subject to enforcement by Commonwealth Court. 12 Pa.C.S.A. 701 et seq. 107

6 67 Pa.C.S.A PUBLIC WELFAR Regulations (a). Authority. By July 1, 2604, the bureau, through the department, shal promulgate regulations establishing rules of procedure as may be necessary t carry out the provisions of this chapter. (h) Advisory committee. The bureau shall establish an advisory commit tee, including individuals experienced in proceedings before the bureau ani other administrative agencies, to provide assistance and guidance in th development and modification of regulations which may be promulgated uncle this section. 2002, Dec. 3, P.L. 1147, No. 142, 20.1, irod. effective. INDEX CONSULT GENERAL INDEX 108