Papendick v. Bowen

658 F. Supp. 1425, 1987 U.S. Dist. LEXIS 3282, 17 Soc. Serv. Rev. 847
CourtDistrict Court, W.D. Wisconsin
DecidedApril 28, 1987
Docket87-C-81-S
StatusPublished
Cited by4 cases

This text of 658 F. Supp. 1425 (Papendick v. Bowen) is published on Counsel Stack Legal Research, covering District Court, W.D. Wisconsin primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Papendick v. Bowen, 658 F. Supp. 1425, 1987 U.S. Dist. LEXIS 3282, 17 Soc. Serv. Rev. 847 (W.D. Wis. 1987).

Opinion

ORDER

SHABAZ, District Judge.

Plaintiff David Papendick commenced this action for injunctive and declaratory relief against the Secretary of Health and Human Services Otis Bowen, the Inspector General of Health and Human Services Richard Kusserow, and the Wisconsin Peer Review Organization. Plaintiff contends that the defendants’ actions terminating his authorization to receive reimbursement for treating Medicare patients have violated his due process rights.

Defendants Bowen and Kusserow have moved for summary judgment. They contend that this Court does not have subject matter jurisdiction because plaintiff has not exhausted his administrative remedies. Defendant Wisconsin Peer Review Organization has moved to dismiss plaintiff’s complaint, contending that there is no justi-ciable case or controversy.

FACTS

Plaintiff David Papendick is a Wisconsin resident who has been engaged in the general practice of medicine in Algoma, Wisconsin since 1962. Defendant Otis Bowen is the Secretary of the United States Department of Health & Human Services. Defendant Richard Kusserow is the Inspector General in charge of the Office of the Inspector General (OIG) within the Department of Health & Human Services. Defendant Wisconsin Peer Review Organization (WiPRO) is a Wisconsin corporation to which the Secretary has delegated responsibility to review the treatment of Medicare cases by Wisconsin physicians. WiPRO has its principal headquarters in Madison, Wisconsin.

Plaintiff became eligible to be reimbursed by the government for the medical expenses of persons eligible for Medicare benefits when the Medicare program began in 1965. Since that time plaintiff has treated many such patients. Over the last five years Medicare payments have constituted more than half of the gross income of plaintiff’s practice. Over the last five years the gross income of plaintiff’s medical practice has averaged approximately $600,000 annually. Most of that amount has paid employee’s salaries and overhead expenses. Plaintiff’s personal net income over the last five years has fluctuated between approximately $120,000 and approximately $200,000 per year.

On May 22, 1986, plaintiff received a letter from WiPRO that stated as follows:

WIPRO has reviewed medical records pertaining to your medical practice. As a result of this review, WIPRO has iden *1427 tified three cases in your medical practice in which it has initially determined are gross and flagrant violations of the obligations under Section 1156 of the Social Security Act. WIPRO has also determined that you had control (influence or authority) over the services or items which were improperly or inappropriately ordered or furnished in these cases.
A copy of each of the medical records used by WIPRO in arriving at this determination is enclosed. Also enclosed is a synopsis of each of the cases which are supported by the enclosed medical records. Each synopsis identifies each case reviewed by WIPRO, the issues raised by WIPRO and the conclusion by WIPRO. WIPRO will follow the procedure outlined in Transmittal #6 in the further resolution of this matter; a copy of this Transmittal is enclosed with this letter for your review and reference.
It has also been determined that the violations of your obligations under Section 1156 of the Social Security Act are serious enough to warrant recommending to the Department of Health and Human Services that sanctions be imposed on you pursuant to Federal statute and regulations. The sanction to be recommended is exclusion from participation in the Medicare program for a period of twelve (12) years.
By this letter you are hereby formally invited to submit to WIPRO within thirty (30) days of your receipt of this letter, additional information which you feel might modify its position and/or a written request to meet with WIPRO staff and physicians to review and discuss Wi-PRO’s determination in this matter.

Transmittal # 6 required the WiPRO to send plaintiff, in conjunction with its initial determination letter, a copy of the material used in arriving at its determination. Wi-PRO, however, did not send plaintiff copies of the written reports prepared by the doctors who initially reviewed the medical records of the three patients whose care was the subject of the sanction recommendation.

Plaintiff responded to the initial determination letter by sending a lengthy letter to WiPRO, in which he explained some of the decisions he had . made in the care of the three patients identified by WiPRO. On June 25, 1986, plaintiff told Michael Rode, Regional Manager of WiPRO, that he did not wish to meet with the Regional Review Committee of WiPRO concerning the initial determination. Rather, plaintiff asked that in lieu of appearance, the Committee review the written materials he had mailed and the tape recordings of meetings he had with the Northeast District Review Council of WiPRO’s predecessor, WisPRO. These tape recordings did not deal with the three cases WiPRO had identified.

On August 26, 1986, WiPRO sent plaintiff a letter stating that it had submitted a recommendation to the OIG and the Secretary that plaintiff be excluded from participation in the Medicare program for 12 years. The letter also erroneously stated that plaintiff could submit additional information to the OIG “within 30 days of the date of this letter.” The letter should have stated, according to Transmittal #6, that plaintiff had “30 days from the date of receipt of this final notice to submit any information to the OIG.”

After plaintiff retained an attorney, his attorney became aware of WiPRO’s August 26,1986 letter. In an October 4,1986 letter to OIG, plaintiff’s attorney stated, when sending additional information to the OIG, that:

Dr. Papendick also received his copy of the August 26, 1986 letter ... on September 4, 1986. By the terms of transmittal number 6 of the Peer Review Organization Manual, any additional submissions on behalf of Dr. Papendick are due 30 days after his receipt of WiPRO’s recommendation for sanctions. We are transmitting, under cover of this letter, such additional submissions on Dr. Pa-pendick’s behalf, by Federal Express Zap Mail, which guarantees same-day delivery, on October 4, 1986, so that they reach you on the thirtieth day after Dr. Papendick’s receipt of WiPRO’s recommendation.

On December 23, 1986, the OIG issued its decision. The decision stated:

*1428 After a careful review of all the evidence of record, and acting on the authority delegated to me by the Inspector General of the Department of Health and Human Services, I have determined that I agree with the conclusion of the PRO that in the case numbers cited above you grossly and flagrantly violated your obligations under section 1156.
I have also determined that you have demonstrated a lack of ability substantially to comply with the obligations imposed on you by section 1156(a) of the Social Security Act.

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Cite This Page — Counsel Stack

Bluebook (online)
658 F. Supp. 1425, 1987 U.S. Dist. LEXIS 3282, 17 Soc. Serv. Rev. 847, Counsel Stack Legal Research, https://law.counselstack.com/opinion/papendick-v-bowen-wiwd-1987.