State College Manor Ltd. v. Commonwealth, Department of Public Welfare

498 A.2d 996, 92 Pa. Commw. 89, 1985 Pa. Commw. LEXIS 1185
CourtCommonwealth Court of Pennsylvania
DecidedSeptember 25, 1985
DocketAppeal, No. 456 C.D. 1984
StatusPublished
Cited by12 cases

This text of 498 A.2d 996 (State College Manor Ltd. 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
State College Manor Ltd. v. Commonwealth, Department of Public Welfare, 498 A.2d 996, 92 Pa. Commw. 89, 1985 Pa. Commw. LEXIS 1185 (Pa. Ct. App. 1985).

Opinion

Opinion by

Senior Judge Barbieri,

' State College Manor (iSCM) appeals here the order of the Department of Public Welfare’s (DPW) Office of Hearings and Appeals adopting the recommendation of the hearing officer denying SOM’s appeal from the decision of the Office of Medical [91]*91Assistance which denied payment for medical assistance services rendered by SOM because correctly completed invoices were not submitted ,to the Department within 180 days of the date of service.

State College Manor is a facility which provides skilled and intermediate nursing care to appproximately 173 patients. During the period from June, 1982 to December, 1982, SCM provided services to patients eligible under medicaid in the approximate amount of $85,000.00. Invoices for services rendered, some new and some resubmitted, were rejected and payment was denied as the invoices had not been submitted within the requisite 180 days from date of service.

Section 1101.68 of the Medical Assistance Manual, 55 Pa. Code §1101.68, provides:

(a) Providers shall use the invoices specified by the Department or its agents when billing for Medical Assistance services or items. Providers shall submit the invoices within six months after the delivery of the services or items. Invoices that have not been completed according to specified instructions or that lack any required documentation will be rejected by the Department. In the event that an invoice is rejected by the Department, a remittance advice will be sent to the provider explaining the reason for the rejection. The provider may submit a correct invoice for payment.
(b) Any invoices submitted after the six-month period will be rejected absolutely unless:
(1) A recipient eligibility determination that was required to be made by a CAO was delayed for 30 days or longer; or
(2) Payment is being requested from a third party resource.

[92]*92SCM’s delay in billing DPW was caused by tbe gross negligence of its bookkeeper. The hearing officer, whose decision wras adopted by the Office of Hearings and Appeals, stated that since SCM’s reason for delay did not fit within either of the exceptions provided in the regulation, the appeal must be denied.

SCM requested that the Secretary of DPW reconsider the Office of Hearings and Appeals’ decision. 'The Secretary refused the request after SCM’s petition for review had been filed with this Court.

•• On appeal to this Court, SCM argues that DPW’s regulation, 55 Pa. Code §1101.68, is unreasonable as applied to the facts in this case and the six-month deadline, more stringent than the federal regulation, 42 C.F.R. §447.45(d)(1) (1978), which requires providers to submit claims within one year of the provision of services, is not justified by DPW’s administrative interest. SCM asserts that the regulation is additionally flawed because it fails to distinguish between claims which were initially filed after the six-month deadline and those which were timely submitted, subsequently rejected because not completed according to specified instructions and then resubmitted.

SCM also argues that, .under principles of substantial performance, DPW should not be relieved of its obligation to pay SCM for patient care undisputedly provided and that the equities of this case require that the six-month period not be strictly enforced.

It is well-established that duly authorized and promulgated regulations of an administrative agency have the force of law and are binding on the agency. Newport Homes v. Kassab, 17 Pa. Commonwealth Ct. 317, 332 A.2d 568 (1975). Furthermore, the establishment of these regulations involves agency discretion, and the court will not disturb administrative discretion in [93]*93the absence of fraud, bad faith or abuse of power. Travis v. Department of Public Welfare, 2 Pa. Commonwealth Ct. 110, 277 A.2d 171 (1971), aff'd 445 Pa. 622, 284 A.2d 727 (1971). The scope of review of an administrative regulation is therefore limited to a determination of whether there has been a clear abuse of discretion or a clearly arbitrary action. Savko v. Department of Public Welfare, 47 Pa. Commonwealth Ct. 168, 407 A.2d 152 (1979).

Clearly, there has been no arbitrary action on the part of DPW in the instant case. The stringent six-month time limitation of the regulation of which SCM complains was intended to and does benefit providers: it assures prompt payment to providers and protects providers from payment denials due to circumstances beyond the providers’ control. While we note that 55 Pa. Code §1101.68 does not distinguish between newly submitted invoices and resubmitted invoices and categorically denies payment of all invoices submitted after the six-month deadline, we do not believe that the DPW, in failing to so distinguish, has exhibited the requisite bad faith or abuse of power which would permit this court to disturb the agency’s regulation. That SCM incurred pecuniary loss upon application of the regulation in this instance is not due to any arbitrary action of DPW’s; rather, SCM incurred the loss due to the extreme negligence of its employee for which SCM must take responsibility. That DPW has applied the plain wording of its regulation to necessitate that payment be denied does not make that application either unreasonable or arbitrary; nor does SCM’s failure to timely submit invoices for services provided make application of the regulation unreasonable or arbitrary.

SCM next contends that the principle of substantial performance should prevent forfeiture by SCM of the cost of the health care services provided by SCM.

[94]*94The equitable doctrine of substantial performance developed in contract law for the protection and relief of those who have faithfully and honestly endeavored -to perform their contract in all material and substantial particulars, so that their right to compensation would not. be forfeited by reason of merely technical, inadvertent or unimportant omissions or defects. See Sgarlat v. Griffith, 349 Pa. 42, 36 A.2d 330 (1944). In Department of Public Welfare v. Dauphin County Social Services, 90 Pa. Commonwealth Ct. 295, 495 A.2d 214 (1985), we permitted recovery by Dauphin County of additional monies expended by Dauphin County for day care services it had contracted with DPW to .provide despite the fact the request for reimbursement was submitted after the contract term had expired and in a second adjusted final invoice. DPW had refused to reimburse Dauphin County on the grounds that, reimbursement would require reallocation of funds among budget categories expressly prohibited by contract after the end of the third quarter of the contract.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Celeste Learning Center v. DHS
Commonwealth Court of Pennsylvania, 2021
City of Philadelphia v. Sessions
280 F. Supp. 3d 579 (E.D. Pennsylvania, 2017)
Casey Ball Supports Coordination, LLC v. Department of Human Services
160 A.3d 278 (Commonwealth Court of Pennsylvania, 2017)
Presbyterian Medical Center v. Department of Public Welfare
792 A.2d 23 (Commonwealth Court of Pennsylvania, 2002)
Winslow-Quattlebaum v. Maryland Insurance Group
752 A.2d 878 (Supreme Court of Pennsylvania, 2000)
Ashton Hall, Inc. v. Department of Public Welfare
743 A.2d 529 (Commonwealth Court of Pennsylvania, 2000)
Western Pennsylvania Hospital v. Commonwealth, Department of Public Welfare
534 A.2d 582 (Commonwealth Court of Pennsylvania, 1987)
Nayak v. Commonwealth
529 A.2d 557 (Commonwealth Court of Pennsylvania, 1987)
Allied Services for the Handicapped, Inc. v. Commonwealth
528 A.2d 702 (Commonwealth Court of Pennsylvania, 1987)

Cite This Page — Counsel Stack

Bluebook (online)
498 A.2d 996, 92 Pa. Commw. 89, 1985 Pa. Commw. LEXIS 1185, Counsel Stack Legal Research, https://law.counselstack.com/opinion/state-college-manor-ltd-v-commonwealth-department-of-public-welfare-pacommwct-1985.