Greenstein v. Commonwealth

512 A.2d 739, 98 Pa. Commw. 445, 1986 Pa. Commw. LEXIS 2328
CourtCommonwealth Court of Pennsylvania
DecidedJuly 1, 1986
DocketAppeal, No. 999 C.D. 1985
StatusPublished
Cited by8 cases

This text of 512 A.2d 739 (Greenstein v. Commonwealth) is published on Counsel Stack Legal Research, covering Commonwealth Court of Pennsylvania primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Greenstein v. Commonwealth, 512 A.2d 739, 98 Pa. Commw. 445, 1986 Pa. Commw. LEXIS 2328 (Pa. Ct. App. 1986).

Opinion

Opinion by

Judge MacPhail,

Sidney Greenstein, M.D. (Petitioner) petitions for review of the Department of Healths (Department) approval of Pennsylvania Blue Shields (PBS) termination of Petitioner as a participating doctor.

The issue presented is whether Petitioner was entitled, under constitutional due process or the Administrative Agency Law (Law),1 to a hearing before the Department.

Petitioner was a participating PBS doctor in Philadelphia, Pennsylvania. The “Participating Doctors Agreement with Pennsylvania Blue Shield” (Agreement), which Petitioner signed, provided, in pertinent part:

I will perform services for Blue Shield Subscribers, make reports to Blue Shield concerning such services and accept compensation therefor, as provided for in the Blue Shield Regulatory Act, as heretofore or hereafter reenacted or amended, and the By-laws, the applicable Rules and Regulations, the applicable Subscription Agreements or Master Contracts, and the applicable Fee Schedules or Prevailing Fee Program, all as heretofore or hereafter adopted or entered into by Blue Shield under authority [447]*447of said Regulatory Act, with any required governmental approval.
This Agreement shall continue in effect until terminated by me by giving thirty (30) days’ prior written notice to Blue Shield; or until terminated by Blue Shield with the approval of the Pennsylvania Department of Health.

PBS received several complaints from its subscribers alleging that Petitioner had charged them fees in excess of the PBS allowance. Section B(19) of PBS’s “Regulations for Participating Doctors” (Regulations) requires that:

In the event any Participating Doctor has received, either from PBS or from the subscriber, an amount in excess of the amount determined by PBS to be payable to him with respect to covered services performed for the subscriber, such excess amount shall be returned promptly to PBS, or to the subscriber, as the case may be.

After investigating each complaint, PBS determined that Petitioner had in fact received an amount from each of the complaining patients in excess of the amount determined to be payable with respect to covered services. In each case, PBS notified Petitioner that he could not, pursuant to the Agreement, charge its subscribers in excess of the allowed amounts. Petitioner eventually refunded overcharges to four of the six complainants. PBS reimbursed those subscribers to whom Petitioner refused to make refunds.

By letter dated April 2, 1984, PBS informed Petitioner that refusing to return all excess payments violated the Agreement and would no longer be tolerated. PBS further stated that “[i]n the absence of a change in your position on this matter or your resignation, we will refer your case to the Medical Review Committee [448]*448[(MRC)]2 at the May 1, 1984 meeting.” Petitioner responded by letter conceding that he had charged some of his patients who were PBS subscribers in excess of PBS allowed amounts but that his overcharging was justified: Petitioner averred that his prevailing fee [449]*449profile3 was inadequate to compensate him for laboratory work performed in his office. He further stated that he was willing to work for an amicable resolution and expressed his desire for an “open hearing” before the MRC. By letter dated April 25, 1984, PBS acknowledged Petitioners alleged justification but stated:

[450]*450As noted in your letter, due to your dissatisfaction with your profiles, you routinely charge subscribers in excess of the Blue Shield allowance for covered services performed in the office. As a participating doctor with Pennsylvania Blue Shield, you have agreed to accept the Blue Shield allowance for covered services. Your contractual agreement precludes your charging subscribers in excess of this amount.

In accordance with the By-Laws, the MRC issued a complaint against Petitioner and scheduled a hearing to determine Petitioners status as a participating doctor.

Counsel for Petitioner requested a continuance of the hearing, which was granted. The hearing was subsequently rescheduled for November 8, 1984 at 1:15 p.m. Neither Petitioner nor his counsel appeared at the hearing. PBS presented the testimony of PBSs Manager of Private Business Utilization Review as well as PBSs Professional Service and Review Representative to support its position that Petitioner should be removed from the PBS roster of participating doctors. Several documents substantiating the subscribers’ complaints against Petitioner, PBSs actions with regard thereto, and Petitioner’s responses were introduced into evidence.

[451]*451At the conclusion of the hearing, the MRC moved to suspend Petitioner as a participating doctor. The MRC chairman issued a certificate in support pf the termination, and copies of the hearing transcript, notice of hearing and certificate were forwarded to the Department with PBSs request that the Department approve the termination pursuant to Section 6324(a) of the Professional Health Services Plan Corporations Act (Act).4 Section 6324(a) of the Act states:

(a) Admission to plan.—Every health service doctor practicing within the area covered by any professional health service corporation shall have the right, on complying with such regulations as the corporation may make with the approval of the Department of Health, to register with such corporation for such general or special professional health services as he may be licensed to practice, within that area, but the corporation may, with the approval of the Department of Health, refuse to place the name of any health service doctor on its register. Any professional health service corporation may, with the approval of the Department of Health, remove from its register the name of any health service doctor after due notice and opportunity for hearing for cause satisfactory to the corporation.

(Emphasis added.) The Department formally approved the recommended termination on March 11, 1985.5

Petitioner filed the instant petition for review asserting that he should have been afforded “some kind of [452]*452hearing” before the Department, the agency with the authority to approve or disapprove the termination. He argues that the termination deprives him of his property interest, remaining a participating PBS doctor, and that therefore constitutional procedural due process guarantees apply.

One is entitled to a due process hearing where, by state action, he suffers the loss of a protected property interest. Arnett v. Kennedy, 416 U.S. 134, 164 (1974); Levine v. Department of Education, 79 Pa. Commonwealth Ct. 357, 468 A.2d 1216 (1984). “Property interests are not created by the Constitution, They are created and their dimensions are defined by existing rules or understandings that stem from an independent source such as state law. . . / ” Cleveland Board of Education v. Loudermill, U.S. , ,84 L.Ed.2d 494, 501 (1985), quoting Board of Regents v. Roth,

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Cite This Page — Counsel Stack

Bluebook (online)
512 A.2d 739, 98 Pa. Commw. 445, 1986 Pa. Commw. LEXIS 2328, Counsel Stack Legal Research, https://law.counselstack.com/opinion/greenstein-v-commonwealth-pacommwct-1986.