Christus Health Gulf Coast v. Aetna, Inc. and Aetna Health, Inc., 397 S.W.3d 651

Hospitals sued Aetna for alleged violation of the Texas Prompt Pay Statute regarding timely payment of hospital bills for NYLCare enrollees.
NYLCare delegated claims processing to NAMM; Management Services contracted with Hospitals to provide hospital services for NYLCare enrollees.
Hospitals billed NAMM, which paid hundreds of millions; Aetna paid Management Services a capitated fee but was not directly a party to Hospitals’ contracts.
NAMM/Management Services’ insolvency led Aetna to de-delegate NAMM and assume claims processing, while instructing Hospitals to submit to NAMM.
Trial court granted summary judgment for Aetna; court of appeals held no prompt-pay violation because there was no direct HMO-provider privity.
Court holds 2001 amendment creates regulatory relief, not a private right of action against HMOs; no direct contract between HMO and Hospitals, so no liability.

Issue	Plaintiff's Argument	Defendant's Argument	Held
Does the Prompt Pay Statute require direct HMO-provider privity?	Hospitals contend privity is not required due to delegated networks.	Aetna argues liability only arises from direct HMO-provider contracts.	Direct HMO-provider privity is required; no liability without direct contract.
Does the 2001 amendment create a private right of action against HMOs for delegated-network failures?	Amendment signals enhanced remedies against HMOs.	Amendment provides administrative relief only; no private action.	Amendment provides administrative relief, not a private cause of action.
Do Delegated Network provisions enlarge the HMO’s duties under the Prompt Pay Statute?	Delegation agreements imply HMO responsibility for payments.	Statute remains unaltered; privity governs.	Delegation does not enlarge duties; privity remains essential.
Does Aetna's monitoring/auditing of NAMM/Management Services affect liability under the statute?	Monitoring shows ultimate payment responsibility lies with Aetna.	Monitoring is normal for independent contractor relationships and does not create liability.	Monitoring does not create direct prompt-pay liability.
Should private remedies exist for missteps of delegated networks under modern structure?	Private action should be available against HMOs for delegated-network failures.	Legislature reserved such recourse to the Insurance Commissioner, not courts.	No private obligation imposed; recourse lies with regulatory action.

Christus Health Gulf Coast v. Aetna, Inc., 237 S.W.3d 338 (Tex. 2007) (precedent on prompt-pay and delegated networks)
City of Rockwall v. Hughes, 246 S.W.3d 621 (Tex. 2008) (statutory interpretation guiding de novo review)
Alex Sheshunoff Mgmt. Servs., L.P. v. Johnson, 209 S.W.3d 644 (Tex. 2006) (statutory construction principles for privity and interpretation)
Entergy Gulf States, Inc. v. Summers, 282 S.W.3d 433 (Tex. 2009) (deference to legislative language in statutory interpretation)