McAllen Hospitals, L.P. v. Suehs
2014 Tex. App. LEXIS 2325
| Tex. App. | 2014Background
- THHSC oversees Texas Medicaid; Hospitals are Medicaid providers and submit reimbursement claims.
- OIG UR Unit reviews inpatient necessity under Texas Medical Review Program; may recoup overpayments when not medically necessary.
- Hospitals appealed UR Unit decisions; UR Appeals Unit denied appeals; UR determination labeled final and case closed.
- Hospitals alleged lack of proper notices and sought mandamus, declaratory relief, takings, and de novo review of medical necessity.
- Trial court granted THHSC plea to jurisdiction on most claims; later granted again on judicial-review claims but remanded mandamus issues.
- Appellate court affirms in part, reverses in part, remands mandamus-related questions for further proceedings.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Is recoupment a sanction that triggers further review? | Hospitals contend recoupment is a sanction requiring further administrative appeal. | THHSC argues recoupment is not a sanction and thus not subject to additional review. | Recoupment is not treated as a sanction warranting further review. |
| Do Hospitals have a right to judicial review of UR decisions under APA? | Hospitals claim final UR decision is reviewable under APA, as a contested case. | UR appeal is not a contested case; APA does not apply. | APA does not grant judicial review for the UR decisions here. |
| Did the trial court lack jurisdiction over declaratory and mandamus claims? | Hospitals seek declaratory and mandamus relief regarding notices and procedures. | THHSC argues no jurisdiction for declaratory relief; mandamus merits depend on substantive duty. | Lacked jurisdiction for declaratory relief; mandamus claims remain jurisdictionally proper and remanded. |
| Are Hospitals entitled to judicial review of the final UR determination under APA? | Hospitals argue UR decision is a final agency order subject to APA review. | UR determination not a final contested-case decision; APA inapplicable. | UR decision not a final contested-case order; APA review not available. |
Key Cases Cited
- Heckman v. Williamson Cnty., 369 S.W.3d 137 (Tex. 2012) (plea to jurisdiction de novo review standard)
- Sw. Pharm. Solutions, Inc. v. Tex. Health & Human Servs. Comm’n, 408 S.W.3d 549 (Tex.App.-Austin 2018) (de novo review of jurisdiction and pleadings)
- Bland Indep. Sch. Dist. v. Blue, 34 S.W.3d 547 (Tex.2000) (jurisdiction challenges; pleading liberality)
- Mayhew v. Town of Sunnyvale, 964 S.W.2d 922 (Tex.1998) (due process and notice requirements for takings claims)
- Perry v. Del Rio, 67 S.W.3d 85 (Tex.2001) (procedural due process; meaningful opportunity to be heard)
- A.P.I. Pipe & Supply, LLC, 397 S.W.3d 162 (Tex.2013) (vested rights; jurisdiction via takings analysis)
- City of Webster, 311 S.W.3d 92 (Tex.App.-Austin 2011) (vested property interests and revenue adjustments)
- Brennan v. City of Willow Park, 376 S.W.3d 910 (Tex.App.-Fort Worth 2012) (mandamus jurisdiction where merits not reached)
- West v. Tex. Comm’n on Envtl. Quality, 260 S.W.3d 256 (Tex.App.-Austin 2008) (APA not universal; contested case requirements depend on enabling act)
- Bacon v. Tex. Historical Comm’n, 411 S.W.3d 161 (Tex.App.-Austin 2013) (APA review not applicable to non-contested decisions)
- City of Houston v. Williams, 216 S.W.3d 827 (Tex.2007) (per curiam; standard for sovereign immunity contexts)