Newcap, Inc. v. Dep't of Health Servs.

2018 WI App 40, 916 N.W.2d 173, 383 Wis. 2d 515
CourtCourt of Appeals of Wisconsin
DecidedJune 12, 2018
DocketAppeal No. 2017AP1432
StatusPublished
Cited by9 cases

This text of 2018 WI App 40 (Newcap, Inc. v. Dep't of Health Servs.) is published on Counsel Stack Legal Research, covering Court of Appeals of Wisconsin primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Newcap, Inc. v. Dep't of Health Servs., 2018 WI App 40, 916 N.W.2d 173, 383 Wis. 2d 515 (Wis. Ct. App. 2018).

Opinion

STARK, P.J.

*520¶ 1 This appeal involves efforts made by the Wisconsin Department of Health Services (DHS) to recoup payments it made to Newcap, Inc., a family planning clinic. DHS claims it had legal authority to recoup the amounts in question, pursuant to WIS. STAT. § 49.45(3)(f) (2015-16),1 because Newcap failed to "maintain records as required by [DHS] for verification of provider claims for reimbursement."See § 49.45(3)(f)1. In response, Newcap contends it was not actually required to maintain the specific records at issue in this case. Alternatively, Newcap argues its failure to maintain those records provided no basis for recoupment because other records-which were in Newcap's possession either at the time of DHS's audit *521or at the time of the subsequent hearing-showed that Newcap actually provided the services for which it was paid by DHS.

¶ 2 We conclude WIS. STAT. § 49.45(3)(f) gives DHS authority to recoup payments made to a Medicaid provider when that provider has failed to maintain the records required by DHS, regardless of whether the provider possesses other records that show the provider actually rendered the services in question. We further conclude the provider has an obligation to make the required records available to DHS at the time of DHS's audit, and records subsequently submitted during an administrative hearing are insufficient to defeat DHS's recoupment claim.

*177¶ 3 Nevertheless, we affirm the circuit court's order, which reversed DHS's decision requiring Newcap to repay DHS $185,074.80. DHS concluded it was entitled to recover that amount based on two deficiencies in Newcap's recordkeeping: (1) Newcap's failure to retain invoices documenting its purchase of prescription drugs that it subsequently dispensed to Medicaid patients; and (2) Newcap's failure to include correct National Drug Codes (NDCs)2 on reimbursement claims it submitted to Medicaid. We conclude Newcap was not required to retain the invoices in question, and its failure to do so therefore did not give DHS authority to recoup payments under WIS. STAT. § 49.45(3)(f). We further conclude DHS lacked legal authority to recoup payments based on Newcap's submission of claims with missing or invalid NDCs. We therefore affirm.

*522BACKGROUND

¶ 4 "Medicaid is a cooperative federal-state program through which the Federal Government provides financial assistance to States so that they may furnish medical care to needy individuals." Wilder v. Virginia Hosp. Ass'n , 496 U.S. 498, 502, 110 S.Ct. 2510, 110 L.Ed.2d 455 (1990). DHS administers Wisconsin's Medicaid program, see State v. Abbott Labs. , 2012 WI 62, ¶ 3, 341 Wis. 2d 510, 816 N.W.2d 145, which is also referred to as "Medical Assistance" or "MA." See WIS. STAT. § 49.45 ; WIS. ADMIN. CODE § DHS 101.01 (Dec. 2008). As a general matter, DHS is required to "reimburse providers for medically necessary and appropriate health care services ... when provided to currently eligible medical assistance recipients." WIS. ADMIN. CODE § DHS 107.01(1) (June 2017).3

¶ 5 Newcap operates a Medicaid-certified family planning clinic, which provides reproductive healthcare services to individuals in Brown, Florence, Forest, Marinette, Oconto, and Vilas Counties. On November 5, 2013, DHS initiated an audit of Newcap "to determine whether pharmacy services provided to Wisconsin Medicaid and BadgerCare Plus members were documented and billed appropriately" during the period between January 1, 2010, and December 31, 2011. DHS reviewed Newcap's records from that period during a site visit on November 18 and 19, 2013.

¶ 6 On August 7, 2014, DHS issued its preliminary audit findings. It identified three deficiencies in *523Newcap's billing and recordkeeping practices: (1) Newcap failed to provide "documentation" listing its "acquisition cost" for drugs that it billed to Medicaid; (2) Newcap billed Medicaid "for drugs at a price that was more than the acquisition cost";4 and (3) Newcap submitted claims for provider-administered drugs with either missing or incorrect NDCs. Based on these deficiencies, DHS "recommended *178that Medicaid seek repayment of $1,169,837.10 paid to [Newcap] for claims that were billed in error."

¶ 7 Newcap submitted rebuttal materials challenging DHS's preliminary audit findings. On April 15, 2015, DHS issued a "Notice of Intent to Recover" the significantly reduced amount of $185,074.80. That amount was comprised of: (1) $168,745.46, for 2,738 claims for which Newcap had failed to retain invoices documenting its purchase of prescription drugs; (2) $1,366.64, for eleven claims that Newcap had submitted with invalid or incorrect NDCs; and (3) $14,962.70, for twenty-seven claims that Newcap had submitted without NDCs. DHS abandoned its claim that it was entitled to recoupment based on Newcap having billed DHS for drugs at prices that exceeded their acquisition cost.

¶ 8 Newcap sought administrative review of DHS's Notice of Intent to Recover. An administrative hearing took place on February 23, 2016, before an administrative law judge (ALJ). During the hearing, Newcap presented the testimony of Jennifer Waloway, *524who was hired by Newcap as a nurse practitioner in November 2011 and became its director of community health services in 2014. Waloway conceded Newcap had failed to retain invoices for some of the prescription drugs for which it had billed Medicaid. However, she testified other records in Newcap's possession, such as patient charts, showed the medications in question were actually provided to Medicaid patients. In addition, Waloway testified she worked with Newcap's suppliers after the audit to obtain copies of some of the missing invoices, which were introduced into evidence during the administrative hearing. Waloway also conceded that Newcap had submitted claims to Medicaid with missing or incorrect NDCs. She testified, however, that Newcap had reviewed patient charts and determined Medicaid was properly billed for those medications.

¶ 9 Newcap ultimately raised three arguments in its posthearing brief.

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Bluebook (online)
2018 WI App 40, 916 N.W.2d 173, 383 Wis. 2d 515, Counsel Stack Legal Research, https://law.counselstack.com/opinion/newcap-inc-v-dept-of-health-servs-wisctapp-2018.