In re MID-CENTURY INSURANCE COMPANY OF TEXAS, Relator.
No. 01-12-00446-CV.
Court of Appeals of Texas, Houston (1st Dist.).
Oct. 4, 2012.
169
P. Matthew O‘Neil, Law Offices of P. Matthew O‘Neil, Austin, for Real Party in Interest.
Panel consists of Justices KEYES, MASSENGALE and BROWN.
OPINION
HARVEY BROWN, Justice.
TH Healthcare, Ltd. d/b/a Park Plaza Hospital sued Mid-Century Insurance Company of Texas seeking additional reimbursement for medical services provided to a patient insured by Mid-Century.1
Background
Park Plaza Hospital provided medical services to an injured worker insured by Mid-Century and billed Mid-Century $178,496.41 for the services. Mid-Century paid the hospital $43,812.47 for the services billed. Park Plaza asserts that Mid-Century should have paid $98,173.02 (55% of its billed charges) pursuant to Park Plaza‘s provider services agreement with Beech Street Corporation, a preferred provider organization.2 Mid-Century denies any obligation under the services agreement and asserts that its payment of $43,812.47 was proper pursuant to the DWC‘s outpatient fee guideline. The dispute resulted in this lawsuit, filed by Park Plaza.
Mid-Century filed a plea to the jurisdiction, asserting that its payment dispute with Park Plaza falls within the exclusive jurisdiction of the DWC such that Park Plaza was required to exhaust its administrative remedies with the DWC before filing this action in state court. Because Park Plaza failed to exhaust its administrative remedies before filing suit, Mid-Century contends, the trial court lacks jurisdiction over this case. The trial court denied Mid-Century‘s plea, and Mid-Century filed a petition for writ of mandamus with this Court.
Standard of Review
A plea to the jurisdiction is a dilatory plea; its purpose is “to defeat a cause of action without regard to whether the claims asserted have merit.” Bland Indep. Sch. Dist. v. Blue, 34 S.W.3d 547, 554 (Tex. 2000). A plea challenges the trial court‘s authority to decide a case. Heckman v. Williamson Cnty., 369 S.W.3d 137, 149 (Tex. 2012) (citing Blue, 34 S.W.3d at 553-54). In the context of jurisdictional exclusivity, there is a constitutional presumption that district court jurisdiction “consists of exclusive, appellate, and original jurisdiction of all actions, proceedings, and remedies, except in cases where exclusive, appellate, or original jurisdiction may be conferred by this Constitution or other law on some other court, tribunal, or administrative body.” In re Entergy Corp., 142 S.W.3d 316, 322 (Tex. 2004) (quoting
Whether the legislature has conferred exclusive jurisdiction on an agency is a question of statutory interpretation. Blue Cross Blue Shield of Tex. v. Duenez, 201 S.W.3d 674, 675-76 (Tex. 2006). In construing statutes, we seek to determine legislative intent by interpreting a statute
The DWC‘s Exclusive Original Jurisdiction
The Workers’ Compensation Act gives the DWC exclusive jurisdiction over certain workers’ compensation disputes relating to entitlement to medical benefits, preauthorization of medical care, and reimbursement of medical expenses. See
While the DWC‘s exclusive jurisdiction expressly extends to disputes over a workers’ compensation insurer‘s denial of some or all of the amount of a health care provider‘s bills for medical services rendered, see
Park Plaza argues that this action-in which it disputes the amount Mid-Century has paid on its bills for medical services rendered-falls outside the DWC‘s exclusive jurisdiction because it is a “private network contract dispute.” According to Park Plaza, the DWC‘s jurisdiction extends only to non-network disputes, and this is a network dispute.4 We disagree with Park Plaza‘s contention because the Beech Street network is not a certified
A. The DWC has exclusive jurisdiction over non-network medical fee disputes
“The Legislature has granted extensive authority to the Division to regulate the amounts of reimbursement health care providers may receive under the workers’ compensation system.” Main Rehab. & Diagnostic Ctr., LLC v. Liberty Mut. Ins. Co., 376 S.W.3d 825, 830 (Tex. App.-Dallas 2012, no pet. h.) (citing
The Labor Code recognizes certain exceptions from the DWC‘s health care reimbursement policies and guidelines for health care provided pursuant to health care networks that are certified under Chapter 1305 of the Insurance Code. See
The DWC has created a dispute resolution process, called medical dispute resolution (MDR), for resolving medical disputes within its jurisdiction. See
Fee disputes over non-network health care-i.e., “medical fee disputes“-are resolved by the DWC “pursuant to division rules, including § 133.307 of this subchapter (relating to the MDR of fee disputes).”
When a medical fee dispute arises over “network health care,” as opposed to “non-network health care,” the DWC‘s MDR process does not apply. See
B. This is a “non-network” dispute
Medical fee disputes, as defined in the Administrative Code, include disputes over an insurance carrier‘s reduction or denial of a medical bill, such as Mid-Century‘s reduced payment of Park Plaza‘s bill in this action. See
Park Plaza asserts that Beech Street Corporation formed an informal network of health care providers,9 but it is undisputed that the Beech Street Network is not a certified network under the Insurance Code.10 See Osborn, 2011 WL 4089995, at *5 (holding that trial court lacked jurisdiction over fee dispute involving Beech Street network because evidence did not establish that Beech Street was certified network). The health care services provided by Park Plaza as part of this informal network thus constitute “non-network health care.” See
Because the statutory scheme demonstrates that the legislature has given the DWC the sole authority to make an initial determination of such disputes, the DWC has exclusive original jurisdiction over this action. See Osborn, 2011 WL 4089995, at *5; see also Main Rehab. & Diagnostic Ctr., 376 S.W.3d at 832 (“The statutory scheme demonstrates the Legislature has granted to the Division the sole authority to make an initial determination of a medical fee dispute and that the Division has exclusive jurisdiction over appellants’ claims for the HPSA incentive payments.“); HealthSouth Med. Ctr., 232 S.W.3d at 830-31 (“When the legislature grants an administrative body the sole authority to make an initial determination in a dispute, the agency has exclusive jurisdiction over the dispute.“); Howell, 143 S.W.3d at 435 (“Because the statutory scheme demonstrates that the legislature has granted to the Commission the sole authority to make an initial determination of a medical fee or medical necessity dispute, we hold that the Commission has exclusive jurisdiction over these disputes.“).12
C. The DWC‘s jurisdiction does not exclude disputes involving contracts
Relying on former section 133.307 of the Administrative Code,13 Park Plaza next suggests that, even if this is a “medical fee dispute” that would otherwise be subject to MDR, the DWC does not have jurisdiction over this dispute because it is contract-based. See 37 Tex. Reg. 3833 (current version at
In support of this contention, Park Plaza asserts that the DWC has dismissed disputes similar to this one in the past, pointing to two dismissal notices from other DWC proceedings attached as exhibits to
Park Plaza‘s reliance on former rule (e)(3)(F) is unpersuasive for several reasons. First, it is the legislature‘s prerogative to take jurisdiction over specific disputes out of the courts and place it in an administrative body. See Houston Mun. Emps. Pension Sys. v. Ferrell, 248 S.W.3d 151, 160 (Tex. 2007) (“the Texas Constitution expressly allows the Legislature to grant jurisdiction to administrative bodies rather than the courts“). When the Legislature unambiguously grants jurisdiction to an administrative body, the administrative body has no power to expand or contract that jurisdiction unless authorized to do so by statute. Cf.
Second, former rule (e)(3)(F) does not indicate that the DWC lacked jurisdiction over contract disputes. To the contrary, the rule‘s permissive language indicates that the DWC could elect not to dismiss such requests for MDR and, instead, exercise jurisdiction to decide the dispute. See See 33 Tex. Reg. 3954 (2012) (repealing
Moreover, the DWC has now repealed rule (e)(3)(F), recognizing that “when the dispute is for health care services provided pursuant to a private contractual fee arrangement ... under the [Texas Workers’ Compensation] Act the Division has original jurisdiction to ensure that these contracts comply with applicable statutory requirements....” 37 Tex. Reg. 3833, 3837 (2012). Thus, the DWC has recognized its jurisdiction over disputes such as this one. Although the DWC has clarified (if not altered) its understanding of its own jurisdiction during the pendency of this action, the statutory jurisdictional grant (and thus the DWC‘s actual jurisdiction) remain the same.14 The DWC had, and continues to have, exclusive original jurisdiction over this dispute.
Having concluded that the trial court erred in denying Mid-Century‘s plea to the jurisdiction, we must determine whether mandamus relief is available to remedy the error. “Mandamus relief is appropriate only if the court clearly abused its discretion and the relator has no adequate remedy by appeal.” In re Entergy Corp., 142 S.W.3d at 320. A trial court abuses its discretion when it issues an order it has no power to render or when it acts arbitrarily, capriciously, and without reference to guiding principles. Garcia v. Martinez, 988 S.W.2d 219, 222 (Tex. 1999); McGough v. First Ct. of Appeals, 842 S.W.2d 637, 640 (Tex. 1992).
When a trial court erroneously denies a plea to the jurisdiction, the fact that the party seeking mandamus may be “forced to endure the ‘hardship’ of a full-blown trial” if the appellate court declines mandamus relief is not, alone, sufficient to render remedy by appeal inadequate. In re Entergy Corp., 142 S.W.3d at 321. In the context of exclusive agency jurisdiction, however, appellate courts must also consider whether denying mandamus relief interferes with the agency‘s legislatively mandated function and purpose. Id. Such interference may constitute a “clear disruption of the ‘orderly process of government,‘” such that mandamus is appropriate. See id. (quoting State v. Sewell, 487 S.W.2d 716, 719 (Tex. 1972)).
We hold that mandamus is appropriate here because the denial of Mid-Century‘s plea to the jurisdiction disrupts the orderly process of government by thwarting the legislature‘s schema for administrative resolution of workers’ compensation medical fee disputes. See In re Liberty Mut. Fire Ins. Co., 295 S.W.3d 327, 328 (Tex. 2009) (holding that, where Workers’ Compensation Act vested exclusive original jurisdiction in DWC, trial court‘s failure to grant plea to the jurisdiction was “correctable by mandamus to prevent a disruption of the orderly processes of government“) (citing In re Sw. Bell Tel. Co., 235 S.W.3d at 624; In re Entergy Corp., 142 S.W.3d at 321).
Conclusion
We hold the trial court abused its discretion in denying Mid-Century‘s plea to the jurisdiction. We conditionally grant Mid-Century‘s petition for writ of mandamus and direct the trial court to grant Mid-Century‘s plea to the jurisdiction. We are confident that the trial court will promptly comply, and our writ will issue only if it does not.
Notes
(g) Noncompliance. The insurance carrier is not entitled to pay a health care provider at a contracted fee negotiated by an informal network or voluntary network if:
(1) the notice to the health care provider does not meet the requirements of Labor Code § 413.011 and this section; or
(2) there are no required contracts in accordance with Labor Code § 413.011(d-1) and § 413.0115
(h) Application of Division Fee Guideline. If the insurance carrier is not entitled to pay a health care provider at a contracted rate as outline in subsection (g) of this section and as provided in Labor Code § 413.011(d-1), the Division fee guidelines will apply pursuant to § 134.1(e)(1) of this title (relating to Medical Reimbursement), or, in the absence of an applicable Division fee guideline, reimbursement will be based on fair and reasonable reimbursement pursuant to § 134.1(e)(3) of this title.