376 S.W.3d 825
Tex. App.2012Background
- appellants provided professional services in a designated HPSA for workers’ compensation claims between Aug. 1, 2003 and Mar. 1, 2008.
- appellants claimed a 10% HPSA incentive, paid quarterly, based on amounts paid for services.
- Division of Workers’ Compensation intervened, asserting MDR jurisdiction over medical fee disputes; Liberty Mutual joined.
- trial court dismissed asserting exclusive MDR jurisdiction and failure to exhaust administrative remedies.
- Division rules and Medicare guidelines differ; Texas rules provide per-bill/per-line HPSA payments and require MDR for disputes over reduced payments.
- appellants did not pursue MDR before suit, leading to dismissal and affirmance on jurisdictional grounds.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is the Division’s MDR process the exclusive forum for HPSA incentive disputes? | Appellants argue HPSA is not a medical fee dispute. | Division and Liberty Mutual assert exclusive MDR jurisdiction. | Yes, MDR exclusive; trial court proper. |
Key Cases Cited
- Guaranty Fed. Sav. Bank v. Horseshoe Operating Co., 793 S.W.2d 652 (Tex. 1990) (intervention rules and burdens are governing)
- Bryant v. United Shortline Inc. Assurance Servs., 984 S.W.2d 292 (Tex.App.-Fort Worth 1998) (burden to challenge intervention by motion to strike)
- In re Union Carbide Corp., 273 S.W.3d 152 (Tex.2008) (orig. proceeding; rule 60 and justiciable interests)
- Health-South Med. Ctr. v. Employers Ins. Co. of Wausau, 232 S.W.3d 828 (Tex.App.-Dallas 2007) (exclusive MDR jurisdiction when legislature grants initial determination)
- Thomas v. Long, 207 S.W.3d 334 (Tex.2006) (pervasive regulatory scheme; exclusive agency jurisdiction)
- HealthSouth Med. Ctr., 232 S.W.3d 831 (Tex.App.-Dallas 2007) (exclusive jurisdiction and exhaustion requirement)
- Apollo Enters. v. ScripNet, Inc., 301 S.W.3d 848 (Tex.App.-Austin 2009) (regulatory framework for medical fee disputes)