ManorCare Health Services v. Department of Human Services
ManorCare Health Services v. Department of Human Services - 1557 C.D. 2016
| Pa. Commw. Ct. | May 26, 2017Background
- ManorCare, a nursing facility, applied for MA-LTC benefits on behalf of a resident in Feb 2014; eligibility was determined on June 18, 2015, effective April 1, 2014, with a penalty making benefits start May 5, 2014.
- ManorCare sought retroactive payment for services from May 5, 2014 through April 30, 2015; because invoices were submitted late, it filed an Invoice Exception Request on November 10, 2015.
- The Department denied the exception as untimely under 55 Pa. Code § 1101.68(c)(1) because the exception was not filed within 60 days of the June 18, 2015 eligibility determination.
- ManorCare appealed the BHA denial to the Secretary; after the Secretary did not act within 180 days, ManorCare argued its reconsideration was deemed approved; the Department contended the BHA order was deemed approved (i.e., denial stood).
- This Court treated ManorCare’s petition as timely from the November 14, 2016 deemed denial and considered (1) whether the Secretary’s inaction granted relief to ManorCare, and (2) whether the Invoice Exception Request was timely because ManorCare’s earlier appeal stayed the 60-day filing period.
Issues
| Issue | ManorCare's Argument | Department's Argument | Held |
|---|---|---|---|
| Whether Secretary's 180‑day inaction deemed ManorCare's request for reconsideration approved | Secretary's failure to act within 180 days meant ManorCare's reconsideration was granted | The regulation deems the BHA determination approved, not the Secretary’s inaction to reverse it | The Court held the BHA denial was deemed approved; ManorCare’s claim that the appeal was deemed sustained failed |
| Whether the Invoice Exception Request filed Nov 10, 2015 was timely because the appeal stayed the 60‑day filing period | The appeal of the June 18, 2015 eligibility determination tolled or stayed the 60‑day period, so the Nov 10 filing was within 60 days of the October 26, 2015 appeal decision | Regulations do not provide that an appeal stays the 60‑day period; the 60‑day window ran from June 18, 2015, making the Nov 10 filing untimely | The Court held the 60‑day period ran from June 18, 2015 (deadline Aug 17, 2015); Nov 10 filing was untimely and denial affirmed |
Key Cases Cited
- Grane Hospice Care, Inc. v. Department of Public Welfare, 72 A.3d 322 (Pa. Cmwlth. 2013) (strict compliance with Medical Assistance invoice deadlines required; substantial compliance insufficient)
- Nayak v. Department of Public Welfare, 529 A.2d 557 (Pa. Cmwlth. 1987) (courts require strict compliance when public funds disbursement is at issue)