*1 COMPENSATION TEXAS WORKERS’
COMMISSION, Petitioner,
PATIENT TEXAS ADVOCATES OF Meril, M.D.,
and Allen J.
Respondents.
No. 02-0804.
Supreme Court of Texas.
Argued Sept. 2003. May 28,
Decided *3 statutory authority
еxceeded its estab- guidelines by lish set- policies care ting maximum amounts health providers may be reimbursed for certain injured work- provided medical services ers. consider whether determining performing audits and re- absence of imbursement amounts specified guidelines improperly fee dele- gated fee-setting audit and *4 to authority private entities and whether Leatherbury, Thomas S. El- Vinson & limit possessed authority to kins, L.L.P., Dallas, Schenkkan, P.M. party may time within which a administra- P.C., Dougherty Moody, Graves Hearon & tively dispute Finally, a claim. we address Austin, Hollaway, T. Daniel Hollaway & constitutionality of the reimbursement Gumbert, Houston, Schunck, Phyllis B. guidelines time limitations TWCC and the Winters, Austin, Clark Thomas & Ami- for bring an administrative dis- established to cus Curiae. pute. Abbott, Gen., Greg Atty. Howard G. complied We hold that TWCC with Baldwin, Gen., Atty. Jeffrey First Asst. S. statutory requisites promulgating for Boyd, Thompson Knight, Dewey & E. desig- guidelines fee and acted within its III, Gen., Helmcamp Atty. Barry Asst. рowers limiting specified nated McBee, Gen., Atty. Ross Office of Don fee time to seek reimbursements and the Walker, Gen., Austin, Atty. Office of affirm the dispute resolution. We Petitioner. court of issues. appeals’ judgment on these Aleshire, Bill M.D. Riggs, Jennifer S. Because did not we conclude that TWCC Aleshire, P.C., Austin, Riggs & for Re- entities, delegate we private its to spondent. appeals’ portion reverse the of the court judgment contrary to this conclu- Justice WAINWRIGHT delivered the sion. the constitutional We also overrule Court, opinion of the in which Chief fee reimbursement challenge to TWCC’s PHILLIPS, HECHT, Justice Justice limitations for com- guidelines and time OWEN, O’NEILL, Justice Justice Justice dispute resolution. mencing medical JEFFERSON, SCHNEIDER, Justice SMITH, Justice and Justice BRISTER I. Factual and Procedural joined. Background case,
In this we a new Legislature consider whether the enacted Compensation Compensation response Texas Workers’ Commis- Act Workers’ (TWCC) substantially increasing sion insur- complied rising medical costs and statutory requirements Comp. adopting premiums.1 ance Tex. Workers’ Garcia, guidelines fee for medical 512-13 treatments Comm’n v. (Tex.1995). services. also decide whether created the Act, initially 1. The new 401.001-506.002. located in articles Code. See Tex. Lab.Code through 8308-1.01 8308-11.10 of the Texas We refer to the Labor Code because this Statutes, Sep- Revised Civil codified on was applies is the version that in this case. appears tember 1993 and now Labor promul- required by statute when Compensation Texas eedures Workers’ Commis- Additionally, PAT agency powers gating the Guideline. gave sion broad rulemak- necessary exceeded its adopt implementa- for the asserts setting ceiling many authority by ing tion and enforcement Workers’ limiting Act. fee reimbursements Compensation Lab. Code medical medical dis- pаrty new the time for a seek § 402.061. functions One TWCC’s year to one from date pute fee reim- resolution guidelines was establish was provided. medical service bursements to health care who the injured challenges validity To treat 413.011. also workers. end, alleging that TWCC ille- agency promulgated the Tex- and Audit Rules delegated fee-setting audit Compensation gally Commission
as Workers’ insurance carriers. adopted Medical Fee Guideline chal- Lastly, PAT raises constitutional reference in Rule of the Texas 134.201 the grounds to the rules on that the lenges Administrative Code. See 28 Tex. Admin. one-year limitation (indicating copies and the time 134.201 MARs of their taking property from constitute a with- the Guideline be obtained just compensation. publication department). out due *5 argues that its enact- response, maximum Guideline contains the allowable (MARs) statutory pro- of the meets reimbursements for thousands ment of placed and the limits procedures. requirements medical The MARs establish cedural upper payments limits on the amount of reimburse- on medical are consistent with authority to payable ments to health care for establish policies guidelines pursuant and to section the listed treatments or services. TWCC rules, promulgated also a of of Labor Code. TWCC claims set now com- 413.011 monly “Dispute to and that it retains its to audit workers’ referred as Rules,” participants Audit which for and establish compensation establish fees, Dispute and insurance carriers review and audit bills medical a means to facili- by providers. simply submitted health care Id. Audit Rules are The of medi- up 133.301-.305.2 rules also set dis- tate insurance carriers’ review provid- procedures by care pute resolution resolve dis- cal claims submitted health agreements necessity over of medical ers. and the
procedures amount reimburse- parties filed cross-motions sum- Requests ments. medi- Id. 133.305. judgment. The court rendered mary trial dispute cal be not resolution must filed TWCC, deny- in favor judgment a final year later than one from date of judgment. summary ing PAT’s motion 133.305(d). service. part appeals court of affirmed holding im- that TWCC adoption part, the Guideline and reversed TWCC’s permissibly delegated Rules at the audit Audit therefore, earners, dispute. Patient Advocates of insurance base (collective- Meril, challenge rule on the constitutional Allen J. M.D. did not Texas and PAT) Rules. and Audit ly claiming initiated this lawsuit to the appeals up- 81. The court of rulemaking pro- not follow TWCC did by changes made the 2000 Dispute and been to the rules 2. The Audit Rules have original amendments, was twice since the suit we refer version of the amended so to this brought parties district court. The have Code. Texas Administrative pleadings incorporate amended their held the remaining portions of the sum- comply with section 2001.030 pro- mary judgment. Id. Both and viding a statement of reasons for or petitioned this Court for review. against adopting the Guideline. For the below,
reasons stated we affirm the court II. Standard of Review of appeals’ judgment overruling PAT’s procedural challenges to enact- parties When both move for sum ment of the Guideline. See 80 mary judgment and the trial grants court one motion other, and denies the the re viewing court should review the summary A. Reasoned Justification judgment presented evidence by both sides The APA requires an administra questions determine all presented agency provide tive justifica a reasoned render the judgment the trial court should tion for a promulgates rule it in the order have rendered. FM Props. Operating Co. adopting it. Tex. Gov’t Code Austin, (Tex. v. City 22 S.W.3d 2001.033(1). is, That the order must 2000). The reviewing court must affirm includе why agency how and reached summary judgment any if summary rule, adopting conclusions it did for judgment grounds are meritorious. FM and the presented conclusions must be in a Props., 22 S.W.3d at Star-Telegram, clear, relatively precise, logical fashion. Doe, (Tex. Inc. 915 S.W.2d Nat’l oflndep. Ass’n Insurers v. Tex. 1995). We now turn pre to the evidence Ins., (Tex. Dep’t sented TWCC and PAT and consider 1996). (1) The order provide also must summary whether judgment properly was summary of the comments received from granted. *6 (2) parties;
interested a restatement of the rule; (3) factual basis for the the III. The Medical Fee Guideline why reasons agency disagrees the with the PAT argues that the version of the Med- comments. Tex. Gov’t ical Fee Guideline that adopted TWCC § 2001.033(1)(A)-(C); Indep. Nat’l Ass’n of invalid because TWCC did not substantial- Insurers, 925 at If 669. an order ly comply with the rulemaking procedures to substantially comply fails with these set forth under certain provisions of the requiremеnts, the rule is invalid. Tex. (APA). Administrative Procedure Act 2001.035(a); Gov’t Code Nat’l Ass’n of (1996).3 Tex. Gov’t Code 2001.002 Spe- Insurers, Indep. 925 at 669. Re cifically, (1) PAT alleges that TWCC failed quiring an agency to demonstrate a ration 2001.033(1) comply to with section of the al connection facts between the before it by APA including not justifica- a reasoned promotes public the (2) Guideline; tion for the failed to comply accountability judicial and facilitates re 2001.023(a) with by section republish- not Insurers, view. oflndep. Nat’lAss’n (3) ing it; amending Guideline after S.W.2d at 669. comply failed to by with section 2002.014 making not a copy of the proposed 134.201, rule adopting the order Rule (4) available to the public; and failed to provided TWCC its reasons for enacting action, Subsequent case, 3. to statutory all further references to the APA, amended September effective APA herein are to the version in effect on 18, 1999, R.S., 1999. Act Leg., of June 76th 15, 1996, February adopted the date TWCC 558, § ch. 2. apply pro- Since these revisions the Guideline. spectively govern and do not the issues in this seventy Reg. over hundred individuals Guideline. Tex. 2361-92 from one (1996). businesses, changes to Among ex- TWCC made things, other TWCC Guideline, including modifications on an nation- plained based extensive section, equipment the durable medical by Compensation al study Workers’ 21 Tex. then the Guideline. adopted comparing Research Institute fee reim- explained states, at 2365-66. Reg. TWCC systems twenty-seven bursement adopting in the Rule 134.201 compensation system’s Texas’s order workers’ public specified procedures changes response these were reimbursements for proposed at In the significantly comment. Id. exceeded national median. rule, for analy- 21 Tex. at stated that reimbursement Reg. 2362. TWCC’s own equipment durable medical would be based sis confirmed this conclusion. Id. TWCC procedure rathеr than “to to- on documentation of enacted move Texas Reg. at 8574. The on the MARs. Tex. position compari- wards a median cost TWCC, however, adopted by final set mar- rule son with other states towards a equip- for durable medical system ket based which based reimbursement reimburses pre-negotiated be- ment the amount [medical] on values set the market carrier, or if provider and there procedures....” explained also tween the rate, no at the fair and pre-negotiated rates was adopting rationale statewide Reg. reasonable amount. utilizing regional instead of MARs. Id. changes agency’s analysis argues found that minimal 2365. equipment expand- section among overall variance in reimbursements durable medical to include regions coverage the various not ed the of Rule 134.201 the state did categories previously affect- justify guideline pеrsons a medical fee developing rule, therefore, proposed regional MARs. Id. ed required republish Rule TWCC was order, Throughout adoption pub- a new provide period 134.201 and evidence, provided objec- factual policy legal- could agency lic before the comment tives, legal rationale for its decisions. ly adopt the Guideline. id. at See 2361-92. order included requires agency give The APA a state summary written comments from days’ thirty at least notice of its intention parties responses interested and TWCC’s *7 rule rule. adopt adopting before the provided to them. Id. 2367-91. TWCC 2001.023(a). The agen- Tex. Gov’t Code reasoning an explanation extensive of the rule Thus, cy proposed must file notice of adopting the Guideline. secretary publication the state for substantially complied with the reasoned 2001.023(b). Register. in the Texas justification requirement of the APA. of, rule consists proposed Notice of a Republication B. among explanation a brief things, other rule, proposed the text of the proposed Rule published proposed rule, request for comments and a on 20,1995 134.201in the October issue of any person. from proposed rule interested notify Register persons Texas (7). 2001.024(a)(l)-(2), §Id. Fee agency’s adopt intent to the Medical following the stan parties appeals, The court of Guideline and allow interested in Insurance Reg. espoused 20 State Board comment on rule. 8573- dard (Tex. (1995). 794, 801 Deffebach, includ proposed 75 v. 1982, n.r.e.), ref'd held App.-Austin writ equipment. ed a section durable medical comments the notice re receiving did not violate Id. at 8573-74. After 650
quirement
of the APA not republishing
significantly changes the issues
in
involved
the modified Guideline.
F.2d final rule 2361, proposed ap- 2363-65. The rale is valid if it does not any major embrace prised parties affected of inten- TWCC’s subjects that were not in described the tion to change the method for determining rule). proposed durable equipment reimburse- proper The standard for notice an- ments agen- and indicated the method the in nounced logical cy and the out- contemplating. Reg. was 20 Tex. Deffebach growth employed by test the federal courts In response 8573-74. to comments TWCC are not A inconsistent. final rule that parties, received from affected the final consideration. calculating for TWGC’s approach rule the comments modified spec- procedures the with equip- complied reimbursements durable of Govern- the change, This ified under section 2002.014 Reg. ment. 21 Tex. at 2365. however, alter issues Code. materially did not ment per- in the rule or affect proposed
raised on previously than those notice. sons other D. of Reasons Statement persuaded that Rule We are therefore challenge procedural is PAT’s last a logical outgrowth 134.201 was a provide failed to concise that TWCC provisions. published for the principal reasons statement of of the Guideline when agency’s adoption Copies C. requires it. APA a requested PAT The pro that argues copies PAT of reasons for desiring a statement person not available to posed Guideline were a rule to submit a against adoption of or in public adopted after the Guideline was adoption not la “either before request analy to side-by-side its final form allow a date of day than 30th after the ter This, however, changes sis of the rule. to § 2001.030. adoption.” Tex. Gov’t Code requirement. is not an APA adopt Rule 134.201 on voted secretary permits APA of state 15, that argues 1996. PAT February required to to omit information otherwise they requested from TWCC May published in if Register pub- be the Texas overruling the of reasons for a statement lication of the information would be cum- urged adoption of against considerations bersome, expensive, inexpe- or otherwise request was made the Guideline. This dient, provided copies that of the omitted days one hundred after the Guideline over at a specified material made available adopted beyond the APA’s was and well Tex. adopting agency. location thirty-day requirement. purpose Gov’t 2002.014. The adoption” par- section 2002.014 to that “the date of argues allow interested a means the effective copy ties to obtain of the material omit- under section 2001.030 date, April ted in this ease was 1996. Register, prior from the Texas which However, clear unam- adoption, they may rule’s enforce the partici- so we 2001.030. See pate rulemaking process. pur- biguous language in the This section Sinclair, Albertson’s, pose present in the Inc. was served case. (Tex.1999).
Guideline, 2001.030 re- pages which is over 400 Section adopted actual date a rule is length, published Regis- was the Texas fers include a reference to rule’s ter 20 and does not by reference on October agree Even if Reg. at 8573-75. In the rule effective date. we were propos- al, adoption” PAT that “the date of un- parties stated interested a rule section 2001.030 is date copies could obtain of the Guideline at the der effect, request PAT’s a statement agency’s place Reg. of business. 20 Tex. takes fall the thir- reasons still would outside at 8574-75. Evidenced numerous in section 2001.030. ty-day deadline comments TWCC received subse- PAT with a provide adoption order refusal quently addressed *9 overruling the 134.201, 21 reasons for Reg. for see at 2366- statement of Rule Tex. urged against adopting 91, proposed Guideline were considerations copies section available, Rule 134.201 did not violate many persons op- and took the timely and 2001.030. portunity meaningful to offer
652
IV. injured Maximum Allowable pensating their de workers and 961;
Reimbursements pendents. Id. at Lujan v. Houston Co., (Tex. Gen. Ins. 756 297 S.W.2d guidelines Rule 134.201 establishes 1988). for reimbursements made for medical or by treatments services rendered health Legislature The with the vested TWCC providers. care When a is estab MAR power authority rules promulgate for particular lished medical treatment necessary implementation as for the service, or the amount of reimbursement Compensa- enforcement the Workers’ payable to a health provider care is the Tex. tion Act. Lab.Code 402.061. Section provider’s lesser fees usual 413.011 of the Labor mandate to Code is a or charges the MAR established to “establish medical policies Medical Fee 21 Reg. Guideline. at guidelines charged relating to ... fees or argues Labor Code paid compen- medical ... services for impose does not authorize TWCC to these injuries, sable relat- including guidelines “caps” medical responds fees. TWCC ing to mеdical payment specific of fees for it that must carry establish the MARs to treatments or services.” Legislature’s out directives 413.011(a)(1) added). These (emphasis Compensation Workers’ Act. TWCC relies guidelines “must be fair and reasonable on section 413.011 sup of Labor Code to designed ... to achieve medi- effective port Legislature contention that 413.011(b). cal While cost control.” Id. granted it upper to set limits on instruct Legislature expressly does not payments medical through use of the TWCC to set máximums on the amounts MARs. carriers can health insurance reimburse proce- specific care medical A state agency administrative dures, expressly require it does TWCC to only powers has those that the effective medical achieve cost control expressly upon confers it im or guidelines establish payment carry plied out the or express functions speсific fees for medical id. services. See given duties or imposed by statute. Pub. Establishing the MARs for treat- Bd., Util. Comm’n v. City Pub. Serv. ments and services is an implied (Tex.2001); S.W.3d 315-16 Pub. Util. reasonably necessary for TWCC GTE-Southwest, Inc., v. Comm’n carry Legislature’s out the intent. See (Tex.1995); S.W.2d R.R. Comm’n Bd., 315-16; City Pub. Serv. 53 S.W.3d at Co., Star Lone Gas S.W.2d GTE-Southwest, 901 Lone (Tex.1992); see also Tex. Gov’t Code Gas, 844 at 685. TWCC’s Star 2001.174(2)(A)-(B) (a reviewing court is therefore a establishment the MARs reverse or must remand a for further case rulemaking power. of its valid exercise if proceedings agency’s an actions violate a statutory provision exceeds The and Audit Rules V. statutory authority). construing a stat ute, objective give our is to cre determine and Audit Rules to the Legislature’s effect intent first ate a which insurance carriers looking to the plain statute’s and common can retrospectively review Albertson’s, meaning. at 960. health providers. claims of care See 28 liberally provisiоns construe the the Tex. Admin. Code 133.301-.305. Compensation carry permit Workers’ Act to out carriers to re retrospectively Legislature’s through of com purpose evident view claims their own offices or *10 discretionary power to of large Id. amount of providers. onsite audit an fees, and set which 133.301(a). audits wishing to conduct conduct § A carrier solely reserved the functions the must notice to provide an onsite audit this turn, argues that consti- PAT pro- the for TWCC. provider, care and health of TWCC’s delegation an improper all tutes must make available documenta- vider authority to fee-setting private subject the audit identified as relevant to tion 133.303(a). the carrier 133.302(a), responds that entities. TWCC the audit. Id. set forth under and audit function obtained from review upon Based the information Audit are vital to review, Dispute Rules pay or the retrospective a carrier must to Legislature’s mandate carrying out the deny the consistent with the results claim (e). reasonable reimburse- 133.304(a)-(b), If fair and provide the Id. review. controlling simultaneously failed ments while the carrier has provider the believes is amount, that it costs. TWCC contends an then the medical pay appropriate to itself to review agency impossible must the carrier to re- provider first ask claim, compliance claim to every medical ensure may and then subse- consider the the millions fee due to request dispute guidelines with the quently file a yearly generated across if the of medical bills resolution with TWCC issue is (m). 133.304(k), compensation the workers’ If still the state under resolved. Id. outcome, of appeals court concluded provider system. The dissatisfied with audit improperly delegated its of Admin- that TWCC has recourse to State Office (SOAH) carriers, and private finally to insurance Hearings pоwers istrative Au- Dispute and 413.031. therefore invalidated courts. Lab.Code The issue of Rules. S.W.3d at 80. dit aspect An additional delegation made private a whether TWCC requires carriers to Audit Rules insurance fee-setting authority was of its specifically develop calculating a method for reim- opin- appeals’ in the court of not addressed amounts there a treat- bursement when is ion. no by providers for ment rendered which been Id. MAR has established. agen an legality administrative 133.304(i). methodology employed entity power private a delegation of cy’s must result in fair and reason- carriers impression first an issue of is able reimbursement amounts to ensure Court, legislative have considered but we provided that medical procedures similar directly to private delegations of re- in similar circumstances receive similar Properties, empha we entities. FM Additionally, Id. carriеrs imbursements. only when delegation that a occurs sized explain must and document methodolo- and the dis entity power is given an they paid, gies used calculate fees promulgate public policy cretion set files, in their claim reference the methods policy, or ascertain rules to achieve any explain and document deviation may existing laws upon conditions which a determining from their usual methods also see operate. A care rate of reimbursement. health Found., Inc. Eradication Tex. Boll Weevil a disagrees with carrier’s provider (Tex. Lewellen, 454, 470-71 v. reimbursement determination 1997); Dallas Auth. Hous. dispute initiate resolution amount 158, 143 S.W.2d 135 Tex. Higginbotham, 133.304(m). §Id. process. (1940). delegates If a such statute interested private Audit authoritative claims FM delegation. private it parties, give insurance carriers Rules *11 654 880;
Props.,
Weevil,
22 S.W.3d at
Boll
Specifically,
952
we consider whether
Dis-
S.W.2d at 470-71.
pute and
private
Audit Rules allow
insur-
ance carriers to execute functions that the
recognize
We
that because a
Legislature
to
delegated
TWCC.
legislative body
pressed
would be hard
to
contend with
detail
every
involved in car
Authority
A. TWCC’s Audit
laws,
rying out applicable
delegation of
TWCC maintains that the auditing pow-
legislative
some
power
necessary
both
granted
by
ers
it
the Labor
Code
proper.
873;
and
22
Props.,
FM
S.W.3d at
separate and
from
auditing
distinct
Weevil,
However,
Boll
952
at 466.
S.W.2d
Dispute
established
and
the Legislature’s
to
power
delegate must
Audit Rules.
claims that
it con-
be exercised with a certain amount of cau
independent
ducts its own
reviews
au-
Weevil,
tion. Boll
legislative disputed of the fees determination for medical treatments reimbursements provider a dis- claims. If a carrier and and services for which no MARs exist. amount, agree on the reimbursement in argument PAT’s context. We consider TWCC, carrier, makes the decision PAT, not the According figures relied subject to review. proper payment, on the year approximately 0.02% of calendar 413.013(1), §§ 10,000,000 See Lab.Code claims the more than 413.031(a); Tex. Admin. Code carriers for reim- submitted to insurance 133.305(b)(3)-(4). 133.304(m), Any (p), disputes. fee Because bursement involved with the outcome by party that is not satisfied these claims included services covered through process did continue the review MARs and services for which MARs a amount determining reimbursement courts. Tex. Lab. SOAH and then the 413.031(d). falls has established no MAR been when delegation. of a legal definition within discussed, follow As earners must that there is no dele- conclude establishing methodolo- Since we TWCC’s par- to audit determining gation medical fees when gies for sys- compensation in the workers’ ticipants in the reimbursing health care fees, not consider to set we need 28 tem or specific guidelines. fee See absence the test set 133.304(i). delegation meets whether Contrary Tex. Admin. Code hold that in Boll forth Weevil. argument, PAT’s does promulgat- аnd Audit Rules were employ carriers to secret methodolo- allow in the provisions with the ed accordance do not gies. and Audit Rules permissible provide Labor Code dis- grant carriers hidden and unbridled medical claims. of carrier review of form arbitrarily payments, set but cretion *14 part this of the court therefore reverse specific pro- on the give them instructions appeals’ judgment. of meth- they cedures are to follow. Id. The odologies employed and the conclusions Limitation One-Year VI. documented and available reached must be Audit Rules re The scrutiny. Id. The request to file a for medical quire party a legitimate ap- out a and Audit Rules set not later dispute resolution with TWCC proach by spec- of medical bills payment the date of the medical year than one after ifying private party’s responsibilities each Admin. Code dispute. in 28 Tex. serviсe limitations, consistent with the en- 133.305(d). no PAT claims that there is abling legislation. Health care authority impose a legislative for TWCC payment submit and insurance bills provider’s time limitation on a health care bills, process carriers review and con TWCC right to seek reimbursement. party may dispute either the reimburse- is one-year that the limitation within tends 413.031(a); ment. Tex. Lab.Code Texas authority Rule because Compensation Commission Med- Workers’ harmony general with the 133.305 is 1996, ical Fee Instruc- General objectives of the statute. To address VI, 2. not allowed to tion at Carriers are issue, language of plain we first look to the policy unilat- public determine and do not legislative to ascertain the Labor Code fees;5 erally they oper- establish medical Albertson’s, at 960. See 984 S.W.2d intent. guidelines and ac- ate within TWCC’s acting if was Then we determine Props., its rules. See FM cordance with delegatеd power scope outside the of its 873, 880; Weevil, 22 at Boll 952 S.W.3d of express implied consent without Additionally, at 470-71. carriers S.W.2d Bd., Pub. Legislature. City See Serv. to ascertain given are not GTE-Southwest, 315-16; 901 53 at S.W.3d existing workers’ upon conditions which Gas, 407; Lone Star 844 S.W.2d S.W.2d FM compensation operate. laws See at 685. 873, 22 Props., the Labor Code en- 143 at 87. There- 413.031 of Higginbotham, Section fore, to administrative review say parties that a insur- titles we cannot issues, proper re- including the reviewing disputed act of medical bills ance carrier’s for, necessity health care. Tex. penalized in ableness and Insurance carriers can be see also 28 415.002(a)(ll), (19); alia, process promptly Lab.Code claims ter failure 134.201(b). unreasonably disputing reason Tex. Admin. and for 658 con- process analyzing
imbursement amount for health care due issues PAT’s challenge. treatments and stitutional services. Section 413.013 requires рromulgate rules to es- A. Procedural Due Process program resolving a these
tablish
disputes.
plain language
A deprivation
personal
thus shows that
Labor Code
property
process
without due
violates
empowered
dispute
a medical
establish
United States and Texas Constitutions.
process.
process
a
must
resolution
Such
Lewis,
County
See
Sacramento v.
523
beginning
impo-
have
an end.
833, 846,
U.S.
118 S.Ct.
140 L.Ed.2d
one-year
sition of the
limitation is consis-
(1998) (the procedural
process
due
1043
express
Leg-
tent with the
duties
guarantee
against “arbitrary tak
protects
upon
confers
Rule 133.305
islature
TWCC.
Shevin,
ings”) (citing Fuentes v.
407 U.S.
is a valid exercise of TWCC’s
to es-
67, 82,
VII. Constitutional meaningful time and nity to be heard at a meaningful PAT claims that in a manner. Mathews El establishment 319, 333, one-year dridge, MARs 96 S.Ct. imposition and the U.S. Rio, (1976); takings Perry limitation of their L.Ed.2d 18 v. Del time constitute *15 Than, (Tex.2001); 85, 901 property process compen- without due and 92 S.W.3d they statutory right sation because have a S.W.2d at 930. only minimally to reimbursement. face, stat the relevant On their claim, appears addresses this but it process due any procedural protect utes they support offer two in contentions are enti rights participants to which (1) process alleged due violations: system. compensation in tled the workers’ cap specified on medi- MARs set fees discussed, pro care previously As a health procedures deprive providers cal dispute resolu right vider has the to seek services, full value their paid payment tion it denied when (2) one-year promulgated limitation amount for the reimbursement reduced insur- and Audit Rules enables rendered. See Lab. medical service deny ance carriers to claims reimburse- 413.031(a). provider A health care
ment no such limit in the where exists fee in excess of the charges who a medical deciding Labor whether the Code. Without dispute resolution to MARs also seek rights claimed to reimbursement constitute that reasonable medi attempt to establish consider PAT’s property rights, vested we justification the deviation. cal exists for rights were vio- process claim that its due 413.031(b). party A that is dis See id. lated. dispute with satisfied the outcome hearing process may of law clause resolution seek a be Texas’s due course ultimately has re process federal due clause are fore the SOAH and and the different, through con courts. textually generally but we course 413.031(d). pre clause the same There was no evidence strue the due course sented to show that the rules TWCC way counterpart. as its federal See Univ. Thаn, 926, prevent taking PAT from advan adopted v. 901 S.W.2d Tex. Med. Sch. (Tex.1995). chal defined Accordingly, rely tage procedures 929 we of.these paid for amounts lenge that addresses the reimbursement federal and Texas case law guidelines designed to subject and reasonable which are to the fair medical services injured provid- PAT and other health care medical care for quality MARs. ensure (2) system 413.011(b), compensation ers in the workers’ workers, Tex. Lab.Code have an to be heard on opportunity cost of effective medical the achievement issue of their medical reimbursements. sys- compensation control the workers’ (3) id., of a tem, the establishment
B.
Due Process
Substantive
regard-
disputes
for resolution of
program
In Bullock v. Hewlett-Packard
services,
ing health care treatments
Co.,
“legislative”
held that
administra
we
413.013(1). By furthering
Legis-
§id.
they
violate due
when
tive rules6
objectives for
work-
lature’s stated
Texas’s
arbitrary
capricious.
628 S.W.2d
system, TWCC had le-
compensation
ers’
(Tex.1982)
(citing
Gerst
Oak
promulgating
gitimate reasons
Ass’n,
Sav. & Loan
Cliff
one-year limitation rule.
MARs and the
(Tex.1968)); see also Daniels v.
oppor-
an
PAT had notice and
Because
Williams,
327, 331,
474 U.S.
106 S.Ct.
heard,
and one-
tunity to be
and the MARs
(1986) (the
due
capricious
legitimate
when it lacks a
rea
Conclusion
VIII.
Bullock,
son to
it.
support
substantially com-
hold that TWCC
Gerst,
707;
see also
(the
plied
procedural requirements
Lewis,
right process. to due concurring
Justice SMITH filed
opinion. SMITH, concurring.
Justice that “a in-
The Court concludes reviewing
surance carrier’s act determining
bills and a reimbursement estab-
amount when no MAR has been legal defi-
lished within [does fall] at 657. delegation.”
nition of a agree separately express my
I but write
understanding that the carrier’s reim-
bursement determination does not consti- an administrative rule and that a de
tute reason-
novo determination of the “fair and rate1 be made in
able” reimbursement will
both the TWCC medical service review2 hearing3 contested-case
and the SOAH previous deference to the carrier’s
without determination.
reimbursement SIMPSON, parte
Ex Danielle
Applicant.
No. 57060-01. *17 Appeals of Texas.
Court of Criminal 30, 2004.
June 134.1(c) by the specific guidelines are established fee 1.See 28 Tex. Admin. Code commission.”). (2004)("Reimbursement not iden- for services guideline be an established fee shall tified in generally Lab.Code 413.031. 2. See at fair and reasonable rates as reimbursed Compensa- Workers’ described in the Texas 413.031(k). Act, period 3. See Tex. Lab.Code tion 413.011 until such