Grane Hospice Care, Inc. v. Department of Public Welfare
2013 Pa. Commw. LEXIS 281
| Pa. Commw. Ct. | 2013Background
- Grane Hospice admitted T.L. to hospice on Sept. 16, 2008; the Department paid under Medical Assistance. Attending physician (Dr. Kush) and hospice medical director (Dr. Lowden) later certified terminal illness. Patient remained in hospice until Oct. 22, 2010.
- Department's retrospective review found documentation and medical-necessity issues for multiple patients, including T.L.; it sought reimbursement for specific periods for which it concluded certification or medical necessity was lacking.
- The Bureau’s ALJ concluded Grane lacked a legible attending-physician signature dated within eight days of admission, so payments from Sept. 24–Oct. 7, 2008 were unsupported; the ALJ also credited the Department’s medical reviewer that after the first four months the patient was "chronic stable," not continuously declining, and ordered reimbursement for Jan. 17, 2009–Oct. 22, 2010.
- Department adopted the ALJ’s recommendation in full; Grane petitioned for judicial review of (1) whether substantial compliance excused the defective initial certification date, and (2) whether the record supported removal of hospice coverage after the initial four months.
- Court applied strict compliance for certification forms when public funds are at issue, and deferred to ALJ credibility findings and substantial-evidence review on the medical-necessity issue.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether "substantial compliance" with initial Certification of Terminal Illness suffices when attending physician's dated signature is illegible | Grane: had timely oral certification, medical director’s written certification, and the attending physician ultimately submitted a signed form; illegible date should not forfeit payment | Dept.: strict regulatory compliance required for claims involving public funds; illegible date means certification not timely documented | Court: strict compliance required; Grane must reimburse for Sept. 24–Oct. 7, 2008 because valid form not in record until Oct. 8, 2008 |
| Whether hospice services from Jan. 17, 2009–Oct. 22, 2010 were medically necessary (i.e., supported by continuing decline) | Grane: patient exhibited weight loss, increased pain meds, contractures, immobility, ulcers, hallucinations — showing significant decline supporting hospice | Dept.: medical review found patient was "chronic stable" after initial period and that records did not document continued decline toward death; hospice coverage not justified | Court: ALJ credited Dept.’s medical expert; credibility/weight findings supported by substantial evidence; affirmed reimbursement for that period |
Key Cases Cited
- Nayak v. Department of Public Welfare, 529 A.2d 557 (Pa. Cmwlth. 1987) (public-fund claims require strict regulatory compliance; substantial compliance insufficient)
- Renee v. Department of Public Welfare, 702 A.2d 575 (Pa. Cmwlth. 1997) (appellate court may not reweigh credibility or evidentiary weight)
- Winston v. Department of Public Welfare, 675 A.2d 372 (Pa. Cmwlth. 1996) (agency factual findings, including credibility, will not be disturbed if supported by substantial evidence)
- Bussoletti v. Department of Public Welfare, 59 A.3d 682 (Pa. Cmwlth. 2012) (scope of appellate review limited to constitutional violations, legal errors, and whether findings are supported by substantial evidence)
- The Piper Group, Inc. v. Bedminster Twp. Bd. of Supervisors, 992 A.2d 224 (Pa. Cmwlth. 2010) (definition of substantial evidence as relevant evidence a reasonable mind might accept)