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Burke v. State ex rel Dep't of Health

November 10, 2009

DAVID M. BURKE, D/B/A DAVE'S DRUG, APPELLANT (DEFENDANT),
v.
STATE OF WYOMING, EX REL., DEPARTMENT OF HEALTH, OFFICE OF HEALTH CARE FINANCING, EQUALITY CARE, APPELLEE (PLAINTIFF).



Appeal from the District Court of Laramie County. The Honorable Michael K. Davis, Judge.

The opinion of the court was delivered by: Kite, Justice.

Before VOIGT, C.J., and GOLDEN, HILL, KITE, and BURKE, JJ.

[¶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 administrative 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 $164,432.24 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?

3. 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 reimbursement, 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, 1993, and the second on August 19, 1998. The Department reimbursed him for the services he provided to Medicaid recipients.

[ΒΆ6] In 2004, the Department requested an audit of Mr. Burke's medical records for the period from January 1, 1998, through January 31, 2003. 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 ...


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