THE NATIONAL JUDICIAL COLLEGE



COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF HUMAN SERVICES

|PROVIDER NAME/ADDRESS: |PROVIDER’S REPRESENTATIVE |PROVIDER’S WITNESS (ES) |

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|Attention: Dr. Sarah Fellowes |Dr. Carl Schneider, Physician Advisor |      |

|Executive Health Resources |      |      |

|Penn State Hershey Medical Center |      |      |

|15 Campus Boulevard |      |      |

|Newtown Square, PA 19073 |      |      |

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|RECIPIENTS INVOLVED: |DEPARTMENT REPRESENTATIVE |DEPARTMENT WITNESS(ES) |

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|Abigail Hammad |Dr. Hong Duc Dang, Medical Director |      |

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|CASE # |BHA ID NUMBER/BHA DOCKET NUMBERS/ISSUE CODES |

|      |22x0161 001 / 920 |

|DATE ADVERSE ACTION MAILED |DATE APPEAL RECEIVED |DATE APPEAL RECEIVED |IR DUE DATE |

| |POSTMARKED AT DHS |AT BHA | |

|9/20/2019 |10/09/2019 |10/9/2019 |1/9/2020 |

|DATE SCHEDULING NOTICE MAILED |RESCHEDULED TO |DATE OF HEARING |START TIME |

| | | |9:03 AM |

|11/26/2019 |      |12/18/2019 | |

| | | |END TIME |

| | | |9:15 AM |

|HEARING LOCATION |TELEPHONE FACE TO FACE OTHER |

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|Philadelphia, PA | |

ORDER

AND NOW, after careful review and consideration of the Recommendation of the Administrative Law Judge, it is hereby ORDERED that the Recommendation be adopted in its entirety.

Either party to this proceeding has thirty (30) calendar days from the date of this decision to request reconsideration by the Secretary of the Department. To seek reconsideration, you must fully complete the enclosed application/petition for reconsideration. The application/petition shall be addressed to the Secretary, but delivered to the Director, Bureau of Hearings and Appeals, P.O. Box 2675, Harrisburg, Pennsylvania, 17105-2675, and must be received in the Bureau of Hearings and Appeals within thirty (30) calendar days from the date of this Order. This action does not stop the time within which an appeal must be filed to Commonwealth Court. The applicant/petitioner shall serve a copy of the application/petition for reconsideration on the opposing party(ies).

The appropriate party(ies), where permitted, may take issue with this Adjudication, and Order, and may appeal to the Commonwealth Court of Pennsylvania, within thirty (30) days from the date of this order. This appeal must be filed with the Clerk of Commonwealth Court of Pennsylvania, 601 Commonwealth Avenue, Suite 2100, P.O. Box 69185, Harrisburg, Pennsylvania 17106-9185.

If you file an appeal with the Commonwealth Court, a copy of the appeal must be served on the government unit which made the determination in accordance with Pa. R.A.P. 1514. In this case, service must be made to: Department of Human Services, Bureau of Hearings and Appeals, 2330 Vartan Way, 2nd Floor, Harrisburg, Pennsylvania 17110-9721, AND Department of Human Services, Office of General Counsel, 3rd Floor West, Health & Welfare Building, Harrisburg, PA 17120.

|Bureau of Hearings and Appeals | |

|Final Administrative Action and Mailing Date | |

|1/8/2020 | |

| |Tracy L. Henry, Esquire Chief Administrative Law Judge |

|cc: |

|Dr. Sarah Fellowes |

|Executive Health Resources |

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|DHS- OMAP |

|Sylvia Rios |

|Sarah Witmer |

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COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF HUMAN SERVICES

BUREAU OF HEARINGS AND APPEALS

APPEAL OF: Executive Health Resources DOCKET NO.: 22x0161 001

15 Campus Boulevard

Newtown Square, PA 19073

ORDER

It is hereby Recommended that the appeal of the Appellant should be SUSTAINED, and the Department is directed to certify the Patient’s July 17, 2019 through July 22,2019 hospitalization as a separate inpatient admission.

January 3, 2020 ________________________

DATE Regina K. Cooper

Administrative Law Judge

COMMONWEALTH OF PENNSYLVANIA

DEPARTMENT OF HUMAN SERVICES

BUREAU OF HEARINGS AND APPEALS

APPEAL OF: Executive Health Resources DOCKET NO.: 22x0161 001

15 Campus Boulevard

Newtown Square, PA 19073

ADJUDICATION

OPENING STATEMENT

This is an adjudication of the appeal of Executive Health Resources on behalf of the Appellant, Penn State Hershey Medical Center from a determination by the Department of Human Services, Office of Medical Assistance Programs (OMAP) [Department] based upon a Diagnosis Related Group (DRG) review. The telephone hearing was conducted from the Bureau of Hearings and Appeals (BHA) Southeast Regional Office in Philadelphia, PA on December 18, 2019. The witnesses were sworn in by the undersigned and testified under oath.

Regina K. Cooper, Administrative Law Judge (ALJ), presided.

EXHIBITS

For the Department of Human Services:

C-1 Curriculum Vitae of Dr. Hong Duc V. Dang (2 pages)

C-2 Notice of Decision and Appeal (5 pages)

C-3 Portions of the Patient’s Medical Record from the admission of July 8, 2019 through July 11, 2019 (22 pages)

C-4 Portions of the Patient’s Medical Record from the admission of July 17, 2019 through July 22, 2019 (18 pages)

C-5 Departmental Regulations 55 Pa. Code §1163.57 (1 page)

For the Appellant:

A-1 Patient’s Medical Record from July 17, 2019 through July 22, 2019 (131 pages)

And Patient’s Medical Record from July 8, 2019 through July 11, 2019 (201 pages)

ISSUE:

The issue is whether the Department correctly and according to regulations denied payment for the inpatient hospital admission of the Patient from July 17, 2019 through July 22,2019 as a separate admission due to it being a readmission within thirty (30) days of a previously certified admission for conditions related to the first admission.

FNDINGS OF FACT

1. The Patient is a 38-year-old woman with a past medical history of uncontrolled diabetes.

2. The Patient presented to the Emergency Department on July 8, 2019 with left flank pain and fever.

3. The Patient received a Computed Tomography Scan (CT).

4. The Patient was diagnosed with L pyelonephritis, a kidney infection.

5. The Patient was treated with Intravenous (IV) antibiotics.

6. The symptoms of L pyelonephritis began resolving and urine cultures at the time of discharge revealed no growth at that time.

7. The Patient was discharged on July 11, 2019 with a seven (7) day course of antibiotic medication to be continued at home.

8. On July 17, 2019, the Patient returned to the Emergency Department with left flank pain and fever.

9. The Patient was again treated with IV antibiotics during her inpatient stay at the hospital.

10. The Patient symptoms were resolving, and the Patient was discharged on July 22, 2019 with an additional ten (10) days of antibiotic medication.

11. On September 20, 2019, the Department issued a notice to the Appellant stating that the request for payment for the readmission for the Patient on July 17, 2019 through July 22, 2019 was being denied due to it being within 30 days of a previously certified admission for conditions related to the first admission. (Exhibit C-2)

12. On October 9, 2019, the Appellant filed an appeal.

13. At the time of the administrative hearing, both parties agreed that both of the Patient’s admissions were medically necessary and that the Patient was not prematurely discharged at the first admission.

DISCUSSION

Department’s Position

The Department’s Representative contends that the Patient’s admission from July 17, 2019 through July 22,2019 should be considered a continuation of care from the Patient’s July 8, 2019 through July 11, 2019 hospitalization. The Department’s Representative contends that the Patient’s two admissions were both related to L pyelonephritis, the kidney infection and the Patient’s uncontrolled diabetes. Per regulations at 55 Pa. Code § 1163.57, if a patient is readmitted within 30 days of discharge for related conditions, the Department makes no payment in addition to the hospital’s original DRG payment and is considered a continuation of care of the first admission. The Department’s Representative further testified that Windber is not met because the Patient was diagnosed with L pyelonephritis and the second admission was caused by the complication of the infection.

Appellant’s Position

The Appellant’s Representative contends that the Windber decision provides the clarification of the application of 55 Pa. Code § 1163.57 for readmissions within thirty (30) days. The Appellant’s Representative stated that both admissions medically necessary. In addition, the Patient was not prematurely discharged, and there was nothing that could have been done in the first admission that would have prevented the second admission. The Appellant’s Representative contends that the Patient’s second admission should be considered a separate admission for payment purposes in accordance with the Windber decision.

APPLICABLE LAW

55 Pa. Code § 1163.57 Payment policy for readmissions

(a) Except as specified in subsection (c), if a recipient is readmitted to a hospital within 30 days of discharge, the Department makes no payment in addition to the hospital’s original DRG payment. If the combined hospital stay qualifies as an outlier, an outlier payment will be made.

(b) If a patient is readmitted within 30 days of discharge for the treatment of conditions that could or should have been treated during the previous admission, the Department makes no payment in addition to the hospital’s original DRG payment.

(c) Except as specified in subsection (b), if a patient is readmitted to the hospital due to complications of the original diagnosis and this results in a different DRG with a higher payment rate, the Department pays the higher DRG payment rate rather than the original DRG rate.

(d) Except as specified in subsection (b), if a patient is readmitted to the hospital due to conditions unrelated to the previous admission, the Department considers the readmission a new admission for payment purposes.

62 P.S. § 443.9 “All of the following shall apply to eligible recipients readmitted to a hospital within thirty days of the date of discharge:

1) “If the readmission is for the treatment of conditions that could or should have been treated during the previous admission, the department shall make no payment in addition to the hospital’s original diagnosis-related group payment. If the combined hospital stay qualifies as an outlier, as set forth under the department’s regulations, an outlier payment shall be made.

2) “If the readmission is due to complications of the original diagnosis and the result is a different diagnosis-related group with a higher payment, the department shall pay the higher diagnosis-related group payment rather than the original diagnosis-related group payment.

3) “If the readmission is due to conditions unrelated to the previous admission, the department shall consider the readmission as a new admission for payment purposes.”

Windber Hospital v. Department of Public Welfare, 545 A.2d 452, 454-55 (Pa. Comwlth. 1988)

“[O]nly if the patient’s condition on the second admission could have been treated during the previous admission is payment denied. How could Windber have treated [the patient] for her second heart attack during her first admission? … Accordingly, we hold that the phrase ‘complications of the original diagnosis’…and the phrase ‘complications of the conditions’…, in this instance must be construed to mean the myocardial infarction, not the underlying coronary artery disease. Were we to interpret these regulations otherwise, the result would be to deny payment for medical treatment which the parties agree was necessary in an instance where the propriety of the initial discharge is not even questioned. We believe that that result would not be one which was within the intendment of the legislature.”

55 Pa. Code § 41.153 Burden of proof and production

(a) Except as provided in subsection (b), the provider has the burden of proof to establish its case by a preponderance of the evidence and is required to make a prima facie case by the close of its case-in-chief.

(c)  The party with the burden of proof has the burden of production, unless otherwise directed by the presiding officer, upon a determination included in the record by the presiding officer that the evidence is peculiarly within the knowledge or control of another party or participant, in which case the order of presentation may be varied by the presiding officer.

ANALYSIS AND CONCLUSION

The issue is whether the Department correctly and according to regulations denied payment for the inpatient hospital admission of the Patient from July 17, 2019 through July 22, 2019 as a separate admission due to it being a readmission within thirty (30) days of a previously certified admission for conditions related to the first admission.

In this case, the Patient was a 38-year-old female with a medical history of uncontrolled diabetes and presented to the Emergency Room with left flank pain and fever. (Exhibits A-1, A-2, C-3, C-4). The Patient was admitted to the hospital and treated for three days with IV antibiotics for fever and L pyelonephritis. At the time of discharge, the Patient’s urine culture showed no growth. The Patient was discharged with a seven (7) day course of antibiotics to be taken at home.

The Patient reported that she completed the course of antibiotics at home and felt good for one (1) day. The next day the Patient returned to the Emergency Room and was readmitted to the hospital with fever and recurrent L pyelonephritis. (Exhibits A-1, C-4). During the second admission, the Patient received IV antibiotics. On July 22, 2019, the Patient was discharged in good condition with an additional ten (10) days of antibiotic medication to be taken at home.

Regulations at 55 Pa. Code § 41.153 (a) state the provider has the burden of proof to establish its case by a preponderance of the evidence and is required to make a prima facie case by the close of its case-in-chief. Thus, the Appellant is responsible for providing evidence that the Patient’s second admission should be considered a separate admission for payment purposes. The Appellant’s Representative argued that the principles of the Windber Hospital, Wheeling Clinic v. Department of Public Welfare, 545 A.2d 452 (Pa. Cmwlth. 1988) (Windber) provided the definitive reasons that show that the second admission should be considered a separate admission. Both admissions were medically necessary. The Patient was not prematurely discharged at the first admission. Ultimately, there was nothing that could have or should have been done to prevent the second admission from occurring.

The ALJ agrees with the Appellant that the principles of the Windber decision apply to this case. In the Windber case, the Commonwealth Court addressed the issue of the application of 55 Pa. Code § 1163.57 and how it applies to second admissions related to the first admission within the specific time frame when both admissions stem from an underlying condition. In Windber, the patient had an underlying condition of coronary artery disease and suffered a second heart attack within seven (7) days of discharge for treatment for a first heart attack. Windber addressed whether both admissions were medically necessary, whether there was anything that could have or should have been done to prevent the second admission from occurring, and whether the discharge from the first admission was proper.

At the time of the administrative hearing, there was no dispute that the Patient’s admissions on July 8, 2019 and July 17, 2019 were medically necessary. Both parties were also in agreement that the Patient received the appropriate level of care and was appropriately discharged on July 11, 2019.

Further, nothing could have or should have been done during the first admission to prevent the second admission from occurring. Regulations at 55 Pa. Code §1163.57 (d) state except as specified in subsection (b), if a patient is readmitted to the hospital due to conditions unrelated to the previous admission, the Department considers the readmission a new admission for payment purposes. In this case, the ALJ finds that the Patient’s July 17, 2019 admission was unrelated to the first admission as it could not have been prevented and should be considered unrelated for payment purposes in accordance with Regulations at 55 Pa. Code §1163.57 (d). Accordingly, the Appellant’s appeal is sustained. An appropriate recommendation will be made to the Chief Administrative Law Judge consistent with these findings.

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