Court Opinion

ID: 9636979
Source: CourtListenerOpinion
Date Created: 2023-08-22 14:51:31.605879+00
Date Added: 2024-06-11T13:37:08.296585
License: Public Domain

Justice EAKIN,
dissenting.
I disagree with the majority that the reimbursement claims at issue here, filed under the Pennsylvania Medical Assistance Program prior to 2003, lie properly before DPW’s Bureau of Hearing Appeals (BHA). Because I believe the Board of Claims has jurisdiction over these claims, I respectfully dissent.
As a service provider, Oakmont entered into a provider agreement with DPW. If Oakmont disputed the amount of reimbursement allowed by regulation, the BHA would be the *355correct tribunal to hear that claim. See DPW v. River Street Associates, 798 A.2d 260, 264 (Pa.Cmwlth.2002) (dispute centers on meaning and interpretation of regulations, not whether DPW breached provider agreement by not following regulations); Pa. Pharmacists Ass’n v. DPW, 733 A.2d 666, 673 (Pa.Cmwlth.1999) (because issue involves technical question of interpretation and application of law, initial consideration by DPW is appropriate). But Oakmont does not dispute the amount of reimbursement allowed under the regulation. Instead, Oakmont asserts DPW improperly calculated the reimbursement under the contractual relationship between Oakmont and DPW. Although DPW characterizes the dispute as regulatory, not contractual, the facts do not bear out this view.
Oakmont does not question DPW’s regulations on how to determine reimbursement. Instead, Oakmont’s claim arises from DPW’s application of regulations to the contract at issue. Oakmont argues it performed its obligations under the contract, but DPW underpaid for the services. In other words, Oakmont does not claim it is entitled to a higher rate or a different rate than the regulations provide, or that the underlying regulations are inadequate, but rather that it is entitled to more money under the regulations as they exist. As noted by the Commonwealth Court dissent, “Oakmont’s claim sounds in contract. Although that contract incorporates by reference certain rate level regulations of DPW, the contract is the source of Oakmont’s rights.” DPW v. Presbyterian Med. Center of Oakmont, 826 A.2d 34, 41 (Pa.Cmwlth.2003) (Leavitt, J., dissenting).
Until 2002, Pennsylvania courts have consistently applied contract law to similar claims and held that the Board is the proper body to resolve them. In DPW v. Divine Providence Hosp., 101 Pa.Cmwlth. 248, 516 A.2d 82 (1986), the court determined the Board had jurisdiction over a case which it determined “[did] not involve a question of eligibility or provider breach, but concerns the question of whether DPW breached the provider agreement by not following its own regulations.” Id., at 84. In DPW v. Shapiro, 91 Pa.Cmwlth. 64, 496 A.2d 887 (1985), the court determined the Board had *356jurisdiction over a reimbursement dispute between DPW and a doctor. There was no question the doctor had performed services which were reimbursable; DPW denied payment because it claimed it had not received invoices from the doctor, in violation of DPW regulations. Although DPW regulations were discussed in order to resolve the dispute, the issue was the application of the regulations to the terms of the provider agreement. Id., at 890.
In Divine Providence, Shapiro, and numerous other cases dating back several decades, DPW asserted BHA was the tribunal with original jurisdiction over provider claims. This position was unavailing until 2002, when the Commonwealth Court agreed in River Street. There, 16 nursing home facilities filed a class action, asserting DPW “violated, misinterpreted or misapplied regulations that govern the computation of certain Medicaid reimbursement rates.” River Street, at 261. The majority here observes that River Street “appeared to draw a distinction based on the complexity of the provider’s claim.” Majority Opinion, at 423. The complexity of the claim itself, however, was not the reason the Commonwealth Court sent the claim in River Street to BHA. That court distinguished River Street from Divine Providence, stating, “the dispute centers on the meaning and interpretation of regulations not whether DPW breached the provider agreement by not following its regulations. At issue is a complicated method of establishing payment rates and setting payment rates. This is within the specific expertise and delegated legislative authority of DPW.” River Street, at 264 (emphasis added).
Oakmont does not contest the regulations governing the overall reimbursement rates, but the computation itself. This is the very difference between a regulatory dispute, as in River Street, and a contractual dispute, as in Divine Providence. In Shapiro, the Commonwealth Court characterized the dispute, stating, “DPW contend[s] ... that it does not owe Claimant the money he claims is due.” Shapiro, at 890. Here, DPW contends it does not owe the money Oakmont claims is due.
*357In 2002, the General Assembly reconstituted the Board and divested it of all prospective claims under the Medical Assistance provider agreements. See Act of Dec. 3, 2002, No.2002-142, P.L. 1147. This legislation resulted in BHA being vested with original jurisdiction over all future disputes arising under provider agreements. The Act directed all pending claims “shall be disposed of in accordance with the Board of Claims Act.” Act 2002-142 § 21.2. It is possible the General Assembly intended this to mean BHA should settle all claims in accordance with the Act, but this tortured interpretation defies common sense; the Board is in a better position than BHA to settle claims in accordance with the Act.
This does not create a “dual track” system for resolving claims, as suggested by Oakmont and discussed in the majority opinion. It maintains the status quo for pending claims, i.e., jurisdiction is maintained by the Board on any claims arising before the Act’s effective date. As noted in the Commonwealth Court dissent, the Board has been deciding claims such as those at issue here for decades; clearly it has the expertise to decide the 20 remaining claims filed before Act 2002-142 removed the Board’s jurisdiction.
Practicality might suggest BHA could handle all claims, both prospective claims and those filed before 2003, but the legislature declined to make it so, and “the jurisdiction of the courts is determined by the General Assembly.” Stackhouse v. Pa. State Police, 574 Pa. 558, 832 A.2d 1004, 1012 (2003) (Eakin, J., dissenting). The General Assembly appropriately exercised its power when it reconstituted the Board. We must not reach beyond the legislation to confer jurisdiction to BHA, when the General Assembly could have, but did not, enact this legislation retroactively.
For the reasons stated above, I respectfully dissent.
Justice BAER joins this dissenting opinion.