Opinion
Argued May 5, 1977
July 21, 1977.
Public assistance — Scope of appellate review — Administrative Agency Law, Act 1945, June 4, P.L. 1388 — Findings of fact — Substantial evidence — Error of law — Violation of constitutional rights — Pennsylvania Medical Assistance Program — Barring physician's participation — Inadequate records — Notice of charges — Commingling of prosecutorial and judicial functions.
1. Under the Administrative Agency Law, Act 1945, June 4, P.L. 1388, review by the Commonwealth Court of Pennsylvania of a decision of the Department of Public Welfare barring a physician from participation in the Pennsylvania Medical Assistance Program is to determine whether the decision was in accordance with law, the findings of fact were supported by substantial evidence or constitutional rights were violated. [205]
2. A physician who fails to keep records sufficient to justify the nature of the treatment performed or the charges therefor as required by the Department of Public Welfare is properly barred from participation in the Pennsylvania Medical Assistance Program. [205-6]
3. A party cannot successfully assert that adequate notice of charges was not received when he stipulated to the charges prior to hearing and requested no continuance. [206]
4. An objection to an improper commingling of prosecutorial and judicial functions in an administrative proceeding cannot be sustained where the functions were performed by different persons. [207]
Argued May 5, 1977, before Judges CRUMLISH, JR., WILKINSON, JR. and BLATT, sitting as a panel of three.
Appeal, No. 1288 C.D. 1976, from the Order of the Department of Public Welfare in case of Appeal of: Stephen Stoffan, M.D., No. A-75-57.
Physician barred from participation in Pennsylvania Medical Assistance Program by Commissioner for Medical Programs. Physician appealed to the Department of Public Welfare. Appeal denied. Physician appealed to the Commonwealth Court of Pennsylvania. Held: Affirmed.
Bresci R. P. Leonard, with him Robb, Leonard Edgecombe, for appellant.
Robert S. Englesberg, Assistant Attorney General, with him Robert P. Kane, Attorney General, for appellee.
Dr. Stephen Stoffan, M.D. (Appellant) appeals the decision of the Department of Public Welfare (DPW) which barred him from further participation in the Pennsylvania Medical Assistance Program (Program) and denied him payment of claims for services which he allegedly rendered.
The Program reimburses participating physicians for medical services rendered to DPW recipients. After a hearing, Appellant was barred from the Program due to his failure to maintain medical records which would support his invoices submitted to DPW. Appellant objects to the decision on many ingenious but foundationless grounds. His objections are as follows: first, DPW regulations requiring records are vague; second, the decision of the hearing officer was not supported by competent evidence; third, the hearing officer was biased; fourth, there was a failure to receive adequate notice of the charges; fifth, there was an improper commingling of judicial and prosecutorial functions within DPW; and finally, that the sentence was disproportionate to the offense.
It need not be said again that the scope of review of this Court in reviewing decisions of an administrative agency is limited by the Administrative Agency Law, Act of June 4, 1945, P.L. 1388, as amended, 71 P. S. § 1710.44, to a determination of whether the decision was in accordance with law, the findings of fact made by the hearing officer were supported by substantial evidence, or the constitutional rights of the defendant were violated.
Accordingly, we affirm the decision of DPW.
A physician receives reimbursement for each patient from DPW by periodically submitting Pa. Form 259 entitled "Standard Medical Invoice." On the top right corner of the invoice is a small square where the doctor records the "Technical Diagnosis." Also, there is a box entitled "Explanation" where Appellant would record whether medicine was prescribed. Directly above the required physician's signature is the following statement: " Vendor's Records and Certification — I hereby certify that services were provided as shown and under conditions 1 through 5 as shown on the reverse of this form." Conditions one and two are:
Appellant did not name the prescription until after the investigation which resulted in this adjudication.
1. I agree to keep such records as necessary to disclose fully the extent of services provided to Medical Assistance patients.
2. I agree to make available to Department of Public Welfare, or its agents, records pertaining to payments for services provided to Medical Assistant patients.
Appellant admits that the only medical record he kept was the invoice itself, with its one or two word technical diagnosis. This failure to maintain proper records led to Appellant's elimination from further participation in the Program. According to the record, Appellant had been charged in 1969 with failing to keep proper records but, upon his agreement to keep the records required by the Program administrator, was permitted to continue in the Program.
Appellant contends that the notation on the invoice, together with his recall, are a sufficient and adequate record. We have no hesitation in affirming DPW's decision that Appellant's records were inadequate. Aside from the obvious need for a record so that another physician would be able to determine the proper course of treatment in emergencies, DPW requires supporting records to determine whether the physician is genuinely entitled to reimbursement and to guard the Program against fraudulent claims. In that regard, we hold that Appellant's records are patently inadequate.
The remainder of Appellant's contentions require cursory treatment. There is no basis for his contention that the facts found by the referee were not supported by competent evidence. Most were admitted by Appellant, except that he denies the conclusion that his record keeping was inadequate. Appellant's claim that the hearing officer was biased is totally without foundation. Appellant's argument that he failed to receive adequate notice of the charge against him is vitiated by the fact that he stipulated to the charges prior to the hearing and never requested any continuance in order to prepare his defense. His contention that there was an improper commingling of prosecutorial and judicial functions cannot be sustained because these functions were performed by different persons. See State Dental Council and Examining Board v. Pollock, 457 Pa. 264, 318 A.2d 910 (1974). Finally, in these circumstances, our review of the record leads us to conclude that the judgment and conclusions by DPW were proper.
Accordingly, we
ORDER
AND NOW, this 21st day of July, 1977, the decision of the Department of Public Welfare is hereby affirmed.