HARRISBURG – In a decision filed May 26, the Commonwealth Court of Pennsylvania has affirmed a decision denying a health care company an invoice reception request.
The Bureau of Hearings and Appeals had previously denied ManorCare Health Services Pittsburgh's request on the grounds that it was untimely. ManorCare, however, argued that the Bureau erred in its decision and appealed to the Commonwealth Court.
The controversy began in February 2014 when ManorCare applied for Medical Assistance and Long-Term Care benefits on behalf of a resident at one of its facilities. In order to be deemed financially eligible, that patient transferred assets totaling $10,000, so a penalty period was applied to their eligibility date, moving it from April 1, 2014, to May 4, 2014. That decision was made on June 18, 2015, and ManorCare appealed the changed date, but was denied in October 2015.
After the appeal, on Nov. 10, 2015, ManorCare sought payment for the patient for May 5, 2014, to April 30, 2015. However, according to Title 55 of the Pennsylvania Code, when a service provider requests payment from the Department of Human Services, they must “submit original or initial invoices to be received by the department within a maximum of 180 days after the date the services were rendered or compensable items provided.”
As that deadline had passed, ManorCare filed an invoice exception request which, according to the code, may be submitted so long as “eligibility determination was requested within 60 days of the date of service and the Department has received an invoice exception request from the provider within 60 days of receipt of the eligibility determination.”
Because that request was submitted more than 60 days after the department determined the resident’s eligibility, on June 18, 2015, it was denied. ManorCare appealed this decision and, according to the appellate court’s written decision, “After a hearing, an Administrative Law Judge (ALJ) issued a recommendation and adjudication denying in part and sustaining in part ManorCare’s appeal… Unsure of what the Order was actually sustaining or denying, ManorCare sought review and clarification of the order from the secretary, who subsequently granted reconsideration on May 18, 2016.”
Several months passed and the secretary made no determination on ManorCare’s appeal, so the company asked the department to pay its invoices, arguing that under the Code, “the secretary’s inaction led to the ‘deemed approval’ of ManorCare’s appeal,” according to the opinion.
Upon further review of the case, ManorCare argued that even if the inaction did not imply approval, “the department erred in finding that its invoice exception request was untimely because its appeal of the department’s June 18, 2015, denial notice stayed the running of the 60-day period that it had to file an invoice exception request,” reads the opinion.
The appellate court found that this argument does not hold, however. The written opinion points out that the regulations do not stipulate that an appeal stays that 60-day period, so ManorCare was obligated to seek a stay if it desired one.
The opinion further points out that “even if there was a regulation that provided for such a stay, that stay would not excuse ManorCare from timely filing invoices for services for May 5, 2014, through April 30, 2015… The Oct. 26, 2015, adjudication did not involve those payments for May 5, 2014, through April 30, 2015.”