Department of Public Welfare v. Devereux Hospital Texas Treatment Network (K.C.)

Justice SAYLOR,

concurring and dissenting.

I agree with the central legal propositions advanced by DPW, namely, that the statutory authorization for placement of juvenile offenders in a DPW-approved medical facility does not control the availability of MA Program funding, but rather, the separate requirements of the MA Program control, and therefore, it may be necessary in certain circumstances to *332 pursue an alternate source of funding for non-MA-Program-approved treatment, in whole or in part, see, e.g., 42 Pa.C.S. § 6306 (establishing a child welfare system to fund the cost of necessary care for children who are adjudicated dependent or delinquent under the Juvenile Act); 62 P.S. §§ 704.1-704-2 (allocating financial responsibility for the child welfare system). In this regard, there are strong cost control factors governing availability of MA Program funding. Additionally, in terms of reimbursement decision making, although certainly a degree of deference is due in favor of a common pleas court directing treatment, I do not believe that DPW should be deemed bound by the placement determination (to which it is not a party), at least in the absence of extraordinary circumstances. Rather, in my view, DPW’s administrative reimbursement decision should be upheld where it is procedurally regular, in conformance with constitutional and statutory dictates, and grounded in findings supported by substantial evidence. See 2 Pa.C.S. § 704.

Additionally, I differ with the majority’s approach to the question of reimbursement for Devereux services rendered to K.T. In this regard, I do not view the distinction between DPW’s regulations concerning the guiding requirement of medical necessity as a prerequisite to reimbursement, see 55 Pa.Code § 1101.61, and the regulation delineating as noncompensable days of inpatient care provided to a recipient who is suitable for an alternate type or level of care, see 55 Pa.Code § 1151.48(a)(15), as material as concerns the hearing examiner’s factual determination (adopted by DPW) that K.T. did not require the inpatient care provided by Devereux during the time period under consideration. Under the rubric of either provision, MA Program funds are simply unavailable, so long as DPW’s finding is grounded in substantial evidence. In this regard, Devereux has conceded the suitability of an alternate level of care and the lack of actual medical reasons to support the continued placement, but has merely advanced the legal argument that its services must be deemed to remain medically necessary for MA reimbursement purposes even after a prescribed coarse of treatment has been completed *333 unless and until an alternative, suitable placement for the juvenile can be made. While the argument for continued funding may have some merit in relation to the obligations of the contracting agency (here, the Philadelphia Department of Human Services) or the child welfare system in general, with respect to MA reimbursement, I would hold that medical necessity and the suitability of an alternative level of care are to be determined according to medical standards of practice as is plainly provided in DPW’s regulations, see 55 Pa.Code § 1101.21, at least in the absence of a successful validity challenge to such regulation (an effort Devereux does not undertake here).

I therefore join in the majority’s disposition of this appeal with respect to reimbursement for services rendered to K.C. and H.B.; with respect to K.T., I respectfully dissent as I would uphold DPW’s denial in that situation as well.