Network for Quality M.R. Services v. Commonwealth, Department of Public Welfare

833 A.2d 271, 2003 Pa. Commw. LEXIS 693
CourtCommonwealth Court of Pennsylvania
DecidedJuly 18, 2003
StatusPublished
Cited by2 cases

This text of 833 A.2d 271 (Network for Quality M.R. Services v. Commonwealth, Department of Public Welfare) 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
Network for Quality M.R. Services v. Commonwealth, Department of Public Welfare, 833 A.2d 271, 2003 Pa. Commw. LEXIS 693 (Pa. Ct. App. 2003).

Opinion

LEADBETTER, Judge.

Before this court are the preliminary objections of the Department of Public Welfare (DPW) and its Secretary (collectively the Department) to the amended [272]*272petition for review filed in our original jurisdiction by Network for Quality M.R. Services in Pennsylvania (Network).1 Network describes itself as a non-profit corporation comprising both health care providers that provide care and services to persons with mental retardation and entities that represent persons with family members with mental retardation. Network providers are reimbursed with Medical Assistance (MA) funds by the Department for services provided to MA recipients with mental retardation. In this action, Network seeks an order requiring the Department to reimburse its providers (for the current year and all future years) for the costs they incur in paying their health care workers (direct care staff) “at the current hourly wages and benefits paid to Commonwealth employees in functionally equivalent positions, or such other hourly wage and benefits as the court determines to be fair and reasonable, and to establish an administrative process that allows those wages and benefits to be maintained at reasonable cost.” First Amended Petition for Review (PFR) at 18.

Network alleges the following facts in its amended petition: Network members operate intermediate care facilities (ICFs) for mentally retarded persons as well as provide care and services to persons with mental retardation in non-institutional settings (group homes, day programs, private residences, etc.). Network members employ direct care staff to provide care and services to persons with mental retardation. Network avers that the Department has developed and implemented a state plan, regulations and guidelines in order to administer the joint federal-state MA program. The regulatory scheme promulgated by the Department to effect the MA program establishes per diem rates and other reimbursement rates for services furnished by health care providers, such as Network members, to MA recipients with mental retardation in ICFs. The per diem reimbursement rate established for each provider is based upon, among other things, hourly wage rate and benefits paid to direct care staff. Network providers must accept the reimbursement determined by the Department as payment in full for services provided to MA recipients. The per diem rates established by the Department do not reimburse Network providers for the actual, reasonable costs associated with “developing and maintaining a consistently stable and well-qúalified direct care work force.” PFR, ¶ 40. Network further avers that the “Department has depressed hourly wage rates and benefits for direct care staff and, as a result, the wage rates and benefits currently used by the Department to set per diems and otherwise determine reimbursement paid to Network Providers are not reasonably related to the actual cost of hiring, training and retaining a consistently stable, properly qualified direct care staff.” PFR, ¶ 41.

Services are also provided by Network members to persons with mental retardation in non-institutional settings through a “Consolidated Waiver,” which allows the provision of non-institutional care/services to persons who would otherwise be treated in an ICF. The Department transfers MA dollars to counties for Consolidated Waiver [273]*273services pursuant to a grant agreement. According to Network, the grant agreement defines, inter alia, the prerequisites of provider participation as well as how the county will authorize funding for Consolidated Waiver services. The grant agreement further provides that the Department’s regulations appearing at 55 Pa. Code Chapter 4300 apply in reimbursing service providers. The Chapter 4300 regulations require payment for actual allowable costs associated with providing service and provide that the Department will participate in compensation for employees of contracted agencies, including direct care staff, “up to the combined prevailing Commonwealth salaries and benefits for functionally equivalent persons.” PFR, ¶ 31 [citing 55 Pa.Code § 4300.83(b)].

Network further avers that the Department’s allocation of funds to counties for Consolidated Waiver services is “without regard to the actual cost of direct care staff and does not permit Counties to reimburse at higher than historical levels of reimbursement for services.” PFR, ¶ 43. Due to the caps the Department places on Consolidated Waiver funding to the counties, Network providers are not reimbursed for the actual cost of their direct care staff and the providers receive as little as half of the wages and benefits that are paid in state-operated facilities for comparable positions. According to Network, Department allocations for wages and benefits are determined arbitrarily by the Department’s budget, rather than by the provider’s actual cost as required by law.

Network also avers that in addition to failing to properly reimburse provider costs, the Department improperly reimburses providers of services in state-operated facilities at a higher rate than private providers despite that both state and private facilities serve MA recipients with similar needs, provide similar services and incur similar costs. Finally, Network avers that it lacks an adequate administrative remedy under the Department’s regulations. Specifically, it contends that the current administrative procedure to challenge per diem rates is ineffective and cannot address the “systemic problem of the Department’s failure to recognize the actual cost of direct care staff ...” PFR, ¶ 64. Further, Network contends that the Department does not decide the vast majority of appeals in a timely manner and that most appeals remain pending for years. According to Network, there is no mechanism to appeal reimbursement amounts for Consolidated Waiver services.

Based upon these factual averments, Network sets forth two causes of action— namely (1) that the Department is violating unspecified provisions of the Public Welfare Code and corresponding regulations by failing to reimburse its ICF providers on a cost-related basis for the costs incurred in recruiting, training and maintaining a stable direct care staff and (2) that the Department is violating the equal protection guarantee of the state constitution by reimbursing state-operated facilities in amounts that exceed the reimbursement to Network providers for the same or substantially similar services.

In response to the petition for review, the Department has filed preliminary objections seeking dismissal of the petition on numerous grounds. We need discuss only the objection that Network providers have failed to exhaust available administrative remedies because it is dispositive, requiring dismissal of the petition.2

[274]*274It is well established that a party challenging administrative action must exhaust available administrative remedies before seeking relief in court. Delaware Valley Convalescent Center, Inc. v. Beal, 488 Pa. 292, 294, 412 A.2d 514, 515 (1980). The requirement that a party must first pursue available administrative remedies serves to ensure that the agency with expertise in the subject area will address the challenge first; it also affords agencies the chance to correct errors, thereby mooting judicial controversies. Pennsylvania Pharmacists Ass’n v. Dep’t of Public Welfare, 738 A.2d 666, 671 (Pa.Crawlth.1999).

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833 A.2d 271, 2003 Pa. Commw. LEXIS 693, Counsel Stack Legal Research, https://law.counselstack.com/opinion/network-for-quality-mr-services-v-commonwealth-department-of-public-pacommwct-2003.