Burke v. State ex rel. Department of Health

2009 WY 138, 219 P.3d 122, 2009 Wyo. LEXIS 150
CourtWyoming Supreme Court
DecidedNovember 10, 2009
DocketNo. S-09-0022
StatusPublished
Cited by1 cases

This text of 2009 WY 138 (Burke v. State ex rel. Department of Health) is published on Counsel Stack Legal Research, covering Wyoming Supreme Court primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Burke v. State ex rel. Department of Health, 2009 WY 138, 219 P.3d 122, 2009 Wyo. LEXIS 150 (Wyo. 2009).

Opinion

KITE, Justice.

[¶1] After a Wyoming Department of Health (Department) audit showed that David M. Burke, d/b/a Dave's Drug, (Mr. Burke) had been reimbursed for services provided to Medicaid recipients in excess of the amount to which he was entitled, the Department sought reimbursement from him. Mr. Burke filed a request for an ad

ministrative hearing, but later withdrew the request, and the Department dismissed the administrative action.

[¶2] The Department then filed an action in district court to recover the excess payments. On the Department's motion, the district court entered summary judgment against Mr. Burke, finding that he was barred from disputing the claim because he failed to exhaust his administrative remedies. The district court entered judgment against him for $164,482.24 plus costs and interest. On appeal to this Court, Mr. Burke claims essentially that the district court improperly and unfairly denied him his day in court. We affirm.

ISSUES

[¶3] Mr. Burke states the issues for this Court's consideration as follows:

1. Is Defendant/Appellant barred from defending this action and having his "day in court" by the doctrine of res judicata ?
2. Did the trial court apply an improper interpretation when attempting to construe the Wyoming Medicaid Rules thereby creating an error of law?
8. Are the Wyoming Medicaid Rules ambiguous?
4. Are the Wyoming Medicaid Rules inconsistent?
5. Is the Appellant entitled to complete discovery before there is an entry of Summary Judgment?

Although rephrased, the Department presents essentially the same issues.

FACTS

[¶4] The Department operates the Wyoming Medicaid program, which provides medical care to low income individuals and families pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., and the Wyoming Medical Assistance and Services Act, Wyo. Stat. Ann. § 42-4-101 et seq. (LexisNexis 2007), otherwise known as the Medicaid Program. Under the program, medical care providers who provide medically necessary services to Medicaid recipients in Wyoming are reimbursed by the federal and state government. To receive reimburse[124]*124ment, providers must sign a provider agreement with the State's Medicaid program.

[¶5] Mr. Burke is a pharmacist licensed in Wyoming. At the time this action arose, he owned three pharmacies in Wyoming, Dave's Drugs, located in Wheatland, Guernsey Drug, and Dave's Drug Lusk. He signed two provider agreements with the Department, the first on August 13, 1998, and the second on August 19, 1998. The Department reimbursed him for the services he provided to Medicaid recipients.

[¶6] In 2004, the Department requested an audit of Mr. Burke's medical records for the period from January 1, 1998, through January 31, 2008. The audit showed that the Department's payments to Mr. Burke exceeded the amounts to which he was entitled by $172,337.36. By letter dated August 3, 2004, the Department notified Mr. Burke of the excess payment and advised him that it had terminated his provider enrollment, he should not submit any further claims for services provided, and it had the right to seek recovery of the excess payments. The Department also advised Mr. Burke that he could seek reconsideration within 20 days of the Department's decision to terminate his provider agreement.

[¶7] Mr. Burke requested reconsideration of the Department's decision. The Department reviewed its decision and notified Mr. Burke that the decision to terminate his provider agreement was final. The Department advised Mr. Burke that he was entitled to an administrative hearing pursuant to the Wyoming Medicaid Rules, Chapter 3, Section 14(f). Mr. Burke requested a hearing on the Department's decision to terminate his agreement.

[¶8] Simultaneously with the administrative proceedings, federal authorities were conducting a criminal investigation of Mr. Burke's Medicaid activities. The administrative matter sat on the Office of Administrative Hearings (OAH) docket for many months and then, in February of 2006, Mr. Burke and the Department filed a joint stipulation stating that the matter was not ripe for adjudication and should be returned to the Department until such time as the federal investigation was completed. No further action occurred with respect to Mr. Burke's request for a hearing on the termination of his provider agreement.

[¶9] On December 138, 2006, the Department sent a certified letter to Mr. Burke requesting reimbursement of the excess payments within 30 days. The Department advised Mr. Burke that he had 20 days to seek reconsideration of the decision pursuant to Wyoming Medicaid Rules, Chapter 39, Section 14(a) and the failure to request reconsideration would preclude any further appeal. The Department further advised Mr. Burke that it would seek alternative means to recover the excess payment amount if payment was not made within 30 days.

[¶10] On February 23, 2007, Mr. Burke filed a request for administrative hearing. The Department referred his request to the OAH which set the matter for a pre-hearing conference. On May 22, 2007, however, Mr. Burke withdrew his request for a hearing. The OAH entered an order recommending the action be dismissed and the hearing vacated. During this same time frame, the State received notification that the criminal investigation had been completed and no criminal charges would be brought against Mr. Burke. On September 25, 2007, in accordance with the OAH recommendation, the Department dismissed the administrative action.

[¶11] In April of 2008, the Department filed a complaint in district court seeking judgment against Mr. Burke in the amount of the excess payments plus the costs of filing and serving the complaint. Mr. Burke filed an answer denying the claims and asserting that he owed the Department nothing. He also filed a counterclaim in which he alleged that the Department owed him $17,000 in unpaid claims and had wrongfully terminated his provider agreements causing a loss of business in an amount in excess of $200,000 per annum. The Department filed motions to dismiss the counterclaims and for summary judgment on its claim. It also filed an amended complaint reducing the amount [125]*125it sought to recover to $164,432.24.1 The district court entered an order allowing the Department to file an amended complaint and, after a hearing, entered an order granting summary judgment in favor of the Department.2 Mr. Burke timely appealed the order.

STANDARD OF REVIEW

[¶2]Summary judgment is appropriate when there are no genuine issues of material fact and the moving party is entitled to judgment as a matter of law. W.R.CP. 56. A genuine issue of material fact exists when a disputed fact, if it were proven, would establish or refute an essential element of the cause of action or defense. Omohundro v. Sullivan, 2009 WY 38, ¶ 7, 202 P.3d 1077, 1081 (Wyo.2009). Because summary judgment involves a purely legal determination, our review is de movo. Id. We review a district court's order granting summary judgment using the same materials and following the same standards as the district court. Id.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Burke v. STATE EX REL. DEPT. OF HEALTH
2009 WY 138 (Wyoming Supreme Court, 2009)

Cite This Page — Counsel Stack

Bluebook (online)
2009 WY 138, 219 P.3d 122, 2009 Wyo. LEXIS 150, Counsel Stack Legal Research, https://law.counselstack.com/opinion/burke-v-state-ex-rel-department-of-health-wyo-2009.