The Pennsylvania Commonwealth Court has decided two companion cases regarding payments to a hospice by the state Medicaid (Medical Assistance) program. In both cases the state Medicaid agency (DPW) was requesting reimbursement for payments it made for care provided to patients (TL) and (RH) who lived much longer than 6 months.
The Pennsylvania Medicaid regulations incorporate the Medicare hospice requirement of certification that the patient’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (See 42 C.F.R. §418.22).
In the TL case the Court upheld an Administrative Law Judge (ALJ) decision to order the hospice to reimburse DPW. Reimbursement was due because the patient had not shown a “decline toward death” which DPW requires for payment. (Unfortunately for the hospice it had failed to raise the issue of the appropriateness of the “decline” standard DPW was applying).
The Court's opinion in TL includes the following statement: “substantial compliance with Medical Assistance regulations is not sufficient, but rather ‘[s]trict compliance with regulations is required where disbursement of public funds is at issue . . . . Men must turn square corners when they deal with the Government.’”
I expect we all have had the experience of being forced to “turn square corners” when dealing with the Government.
In the RH case the court overturned the ALJ ruling that the hospice must reimburse DPW. In RH the basis for the DPW claim was that the hospice did not review the patient’s medical records. But the court noted that DPW regulations did not require the hospice to review the patient’s medical records.
Here are links to the Court's opinions in the two cases:
Grane Hospital TL case: http://www.pacourts.us/assets/opinions/Commonwealth/out/1354CD12_7-25-13.pdf?cb=1
Grane Hospital RH case: http://www.pacourts.us/assets/opinions/Commonwealth/out/1261CD12_7-25-13.pdf?cb=1