VISTA MEDICAL CENTER HOSPITAL, Appellant v. TEXAS MUTUAL INSURANCE COMPANY, Appellee.
Nos. 03-11-00641-CV to 03-11-00643-CV, 03-11-00742-CV to 03-11-00785-CV.
Court of Appeals of Texas, Austin.
Sept. 27, 2013.
Appellant also relies upon Billodeau v. State. See 277 S.W.3d 34 (Tex.Crim.App. 2009). In that case, the Court of Criminal Appeals held that the trial court should have admitted evidence that the child-complainant in that aggravated sexual assault prosecution had made threats to falsely accuse two neighbors of sexual molestation. See id. at 38. The high court held that such evidence supported the defensive theory that the complainant‘s motive in accusing the defendant of sexual molestation was “rage and anger” when he was thwarted. See id. at 42. The evidence proffered in the case under review did not include any evidence that the complainant had falsely accused anyone of sexual molestation or that she had threatened to do so. The facts in Billodeau are materially different from those in the case under review. See id.
Notably, the questions and answers in the offer of proof are not highly probative of the complainant‘s motive or bias or of a specific bias, motive, or interest to testify in a particular fashion, and there is a substantial danger of unfair prejudice from evidence of the complainant‘s sexual relationships with three other individuals, her pregnancy, and her abortion. We conclude the trial court did not abuse its discretion by impliedly concluding that the probative value of this evidence did not outweigh the danger of later admitted she fabricated the story. Id. at 569-70. unfair prejudice and, thus, the proffered evidence was inadmissible under
Having overruled all of appellant‘s issues, we affirm the trial court‘s judgment.
Bryan W. Jones, Mary Barrow Nichols, Texas Mutual Insurance Company, Thomas B. Hudson, Jr., P.M. Schenkkan, Graves, Dougherty, Hearon & Moody, P.C., Austin, TX, for Appellee.
Before Justices PURYEAR, PEMBERTON; and ROSE.
OPINION
BOB PEMBERTON, Justice.
We withdraw our opinion and judgments dated June 6, 2013, and substitute the following in their place. We overrule the motion for rehearing filed by appellee Texas Mutual Insurance Company.
In these appeals, we again consider the scope of the exclusive jurisdiction that the Legislature has vested in the Texas Department of Insurance‘s Division of Workers’ Compensation (the Division)2 to ini
In its principal contention on appeal, Vista asserts that the district court lacked subject-matter jurisdiction to award this monetary relief unless and until there is a final administrative determination that Vista is not entitled to the additional reimbursement it seeks. We agree, and will reverse the district court‘s judgments and remand these causes.
BACKGROUND
Statutory context
Because the parties’ contentions on appeal arise from, and center on, the workers’ compensation act‘s system of regulating medical reimbursement paid to health care providers and resolving disputes about such payments, it is helpful to begin by noting some pertinent features of that system.
The workers’ compensation act establishes a “comprehensive scheme whereby employees who are covered by workers’ compensation insurance and incur ‘compensable’ injuries are provided the exclusive remedy of ‘workers’ compensation benefits,‘” including “medical benefits” (i.e., “all health care reasonably required by the nature of the injury as and when needed“), to be paid by the insurance carrier that covers each worker. Apollo Enters., Inc. v. ScripNet, Inc., 301 S.W.3d 848, 852, 860 (Tex.App.-Austin 2009, no pet.); see
To obtain such reimbursement, the act requires a health care provider to submit a claim for payment to the appropriate workers’ compensation insurance carrier
The act comprehensively regulates the amount of reimbursement that workers’ compensation insurance carriers are to pay health care providers and delegates expansive rulemaking powers to the Division for that purpose. These delegations include the power and duty to promulgate “fee guidelines” that are “fair and reasonable and designed to ensure the quality of medical care and to achieve effective medical cost control.” See
In instances where a carrier denies or reduces payment on a provider‘s bill, the workers’ compensation act entitles either the carrier or the provider to obtain administrative “review” of the claim before the Division, known as “medical dispute resolution.” See
Although a carrier or provider may elect to pay in compliance with the Division‘s order in a medical-fee dispute, at relevant times the workers’ compensation act has provided the aggrieved party a right to a de novo contested-case hearing on the reimbursement or refund claim, in the manner prescribed under the Administrative Procedure Act (APA),9 before an adminis
As with various other disputes that arise under the workers’ compensation act, it is established that this statutory scheme impliedly delegates to the Division (and, in turn, SOAH) exclusive jurisdiction to determine the amount of medical reimbursement that is owed by a carrier to a health care provider under the act and Division rules, subject to judicial review under the APA substantial-evidence standard. See Patient Advocates, 136 S.W.3d at 656-57; Apollo, 301 S.W.3d at 858-71; Texas Mut. Ins. Co. v. Eckerd Corp., 162 S.W.3d 261, 263-67 (Tex.App.-Austin 2005, pet. denied); Howell v. Texas Workers’ Comp. Comm‘n, 143 S.W.3d 416, 434-38 (Tex. App.-Austin 2004, pet. denied).
The stop-loss controversy
The present medical-fee disputes and ensuing litigation originated from a larger controversy concerning a fee guideline that the Division promulgated in 1997 to govern the amount of medical reimbursement that workers’ compensation carriers must pay for inpatient hospital admissions of covered workers. See
The 1997 hospital fee guideline states that a hospital‘s total audited charges from an admission must meet a “minimum stop-loss threshold” of $40,000 in order for the
In response to a torrent of such filings, SOAH consolidated many of the proceedings and assigned them to an en banc panel of ALJs to decide several common issues of construction under the 1997 hospital fee guideline. These issues included the threshold-only versus threshold-plus controversy regarding the stop-loss exception. In January 2007, the en banc panel issued a decision that, in relevant part, agreed with the hospitals’ threshold-only view and held that such providers were required only to show that their total audited expenses from an admission met the $40,000 threshold in order to receive stop-loss reimbursement. Thereafter, ALJs began conducting contested-case hearings in the individual medical-fee disputes pending there and consistently rendered final orders awarding stop-loss reimbursement to providers based solely on findings that the total audited charges from the admission exceeded the $40,000 threshold. In many of these cases, the carrier perfected suits for judicial review from the ALJ‘s final order.13
Large numbers of these administrative proceedings and ensuing suits for judicial review pitted Vista against Texas Mutual. Those parties, along with several intervenors, eventually presented the threshold-only versus threshold-plus controversy for judicial resolution through competing declaratory claims under APA section
The present litigation
Among the medical-fee disputes emanating from the stop-loss controversy and pitting Vista against Texas Mutual were the 47 that gave rise to the present appeals. Each arose when Vista submitted a reimbursement claim to Texas Mutual, the carrier paid only per diem reimbursement on the claim (and issued an EOB reflecting that action), and Vista pursued medical-fee dispute resolution before the Division to recover the full amount of stop-loss reimbursement to which it claimed entitlement. The Division issued an order in each proceeding—in some cases favoring Vista, in others Texas Mutual—and the losing party in each proceeding “appealed” the order to SOAH for a contested-case hearing. The 47 proceedings (like many similar ones) remained pending at SOAH until after the en banc panel‘s decision and the district court‘s subsequent judgment in Vista I favoring the hospitals. Following the district court‘s ruling, ALJs began conducting contested-case hearings in the pending medical-fee disputes. The ALJs disposed of these proceedings with largely parallel orders holding that “[t]he Stop-Loss Methodology applies to this case” and ordering Texas Mutual to pay Vista additional reimbursement accordingly, less the amounts Texas Mutual had already paid under the per diem rates, plus interest on the difference. See
In response to each of the 47 final administrative orders, Texas Mutual paid the additional reimbursement as ordered and
Texas Mutual‘s judicial-review claims were similarly founded on its threshold-plus view of the stop-loss exception. The carrier asserted that the ALJs’ reliance on the threshold-only view in awarding Vista stop-loss reimbursement necessitated reversal of the orders and remand of Vista‘s claims to the Division for redetermination under a proper, threshold-plus, construction of the exception. See
the stop-loss exception required proof of both expenses exceeding the $40,000 threshold and “unusually costly and unusually extensive” services. See Vista I, 275 S.W.3d at 548-51.
Thereafter, Vista acknowledged that the administrative orders awarding it stop-loss reimbursement could not survive judicial review to the extent they rested solely on the legal conclusion that the stop-loss exception applied to all claims meeting the $40,000 threshold and did not additionally require proof of “unusually costly and unusually extensive” services. See id. at 550-51. However, Vista urged that the administrative records in 20 of the 47 cases established an alternative legal basis for applying the stop-loss exception there. Specifically, Vista maintained that Texas Mutual had waived its right to contest whether the hospital services at issue in those proceedings were “unusually costly and unusually extensive,” which in Vista‘s view had the effect of conceding that the stop-loss exception applied by virtue of the ALJ‘s findings that the charges at issue met the $40,000 threshold. Based on that premise, Vista filed in each of these 20 cases a motion for summary judgment seeking to affirm the administrative order. Both Texas Mutual and the Division, which was also a defendant, filed responses in opposition to Vista‘s summary-judgment motions.
However, as Texas Mutual observed in its briefing below, “the real fight” in the district court “[was] about refunds“—spe-
Texas Mutual filed in each case a brief on the merits of its APA judicial-review claims in which it emphasized the monetary component of the relief it sought under that statute. It combined with that brief a motion for summary judgment on its equitable money-had-and-received claim. Texas Mutual insisted that this “refund relief” was urgently necessary to protect the carrier‘s interests in the disputed funds during the interim before a final administrative determination of Vista‘s claims for stop-loss reimbursement. Texas Mutual emphasized filings by Vista‘s parent company, Dynacq Healthcare, Inc., before the U.S. Securities and Exchange Commission indicating that Dynacq was in the process of selling the Vista hospitals due to continued operating losses, that Dynacq classified the hospitals as “discontinued operation[s],” and that the company‘s continuing operations and business plans were focused exclusively on investments in China. Texas Mutual urged the district court that if it “does not order refunds now, in its judgments,” there would be a substantial risk that any payments it made to Vista in excess of the amounts it properly owed “may become uncollectible, as Vis-
Vista filed responses in opposition to Texas Mutual‘s summary-judgment motions in which it objected to an affidavit the carrier had presented. But Vista‘s primary resistance to Texas Mutual‘s monetary claims came in the form of a plea to the jurisdiction it interposed in each case. Vista asserted that the district court lacked subject-matter jurisdiction over the claims because the Legislature had vested exclusive jurisdiction in the Division (and, in turn, SOAH) to determine carriers’ entitlement to “refunds” of “overpayments” of medical reimbursement, subject to judicial review, and the relief Texas Mutual sought fell squarely within the scope of this delegation. In essence, Vista urged that Texas Mutual‘s monetary claims presented a type of medical-fee dispute.
In response to Vista‘s jurisdictional challenges, Texas Mutual acknowledged that the “ultimate” question of whether Vista was entitled to reimbursement under the stop-loss exception was within the Division‘s exclusive jurisdiction to determine on remand and that, through this process, the agency “could order such refunds.” Nonetheless, Texas Mutual insisted that its “refund” claims presented a conceptually distinct issue that lay beyond the Division‘s exclusive jurisdiction over medical-fee disputes—whether it or Vista should be entitled to hold the disputed stop-loss reimbursement amounts at the present time, pending determination of Vista‘s “ultimate” entitlement to stop-loss reimbursement. The Division echoed Texas Mutual in drawing “a sharp distinction ‘between’ a ‘medical fee dispute’ (which includes a determination of the ultimate amount due in the context of a refund demand) and a dispute as to the court‘s authority to award equitable recovery to [Texas Mutual] at this stage of the contested claims process.” It posited that “if the court‘s exercise of its powers in equity does not involve a determination that there has been an ‘overpayment’ or determining [] the payment ultimately due for hospital services, then adjudication of [Texas Mutual‘s] pending refund claims do not seem to compromise the Division‘s original jurisdiction to adjudicate medical fee disputes.”
The 47 suits proceeded to a consolidated hearing on Texas Mutual‘s APA claims, the parties’ summary-judgment motions, and Vista‘s pleas to the jurisdiction. Thereafter, the district court rendered the following judgments:
- In each of the 20 cases in which Vista had filed a motion for summary judgment seeking affirmance of the final administrative order, the district court denied the motion.
- In each of the 47 cases, the district court
- rendered judgment reversing and remanding the administrative order to the Division for further proceedings consistent with Vista I;
- denied Vista‘s plea to the jurisdiction;
- overruled Vista‘s evidentiary objection, granted Texas Mutual‘s summary-judgment motion on its money-had-and-received claim, and rendered judgment awarding the carrier the additional reimbursement it had paid Vista under the now-invalidated administrative order, plus interest. The district court emphasized that “[t]his monetary award is without prejudice to the exclusive jurisdiction of [the Division] to determine on remand in proceedings consistent with [Vista I] the hospital fee dispute ... and to order additional payments that may be due, if any, in accordance with the Texas Labor Code and applicable medical fee guidelines“;
in light of these holdings, dismissed “the other actions pled by Plaintiff Texas Mutual” without prejudice; and - ordered that “[a]ll claims for relief not expressly addressed above are DENIED.”
Vista paid the disputed funds into the court‘s registry and perfected appeals to this Court from each of the 47 judgments. On Vista‘s motion, we consolidated the appeals for purposes of briefing and argument.
ANALYSIS
Vista brings four issues on appeal. Its first, second, and fourth issues seek relief from the district court‘s judgment awarding Texas Mutual monetary relief under an equitable money-had-and-received theory. In its first issue, Vista urges that the district court erred in denying its pleas to the jurisdiction as to Texas Mutual‘s money-had-and-received claims. In its second issue, Vista argues that the district court abused its discretion in granting Texas Mutual‘s summary-judgment motions because it was an abuse of discretion to award relief under a money-had-and-received theory under the circumstances presented here. In its fourth issue, Vista complains that the district court abused its discretion in overruling its objection to Texas Mutual‘s summary-judgment evidence. In its remaining issue, its third, Vista asserts that the district court erred in denying its motions for summary judgment in the 20 cases in which it filed one.
In addition to responding to Vista‘s issues, Texas Mutual brings a cross-point urging that the district court possessed subject-matter jurisdiction to award the monetary relief under the APA, as the carrier had argued below, and that the judgment awards can be affirmed on that alternative theory. Vista disputes that Texas Mutual‘s cross-point sufficed to preserve this contention for appeal and suggests that the APA claims for monetary relief would fall within the Division‘s exclusive jurisdiction in any event.
The Division, as appellee, has also filed a brief joining with Texas Mutual in opposition to Vista‘s third issue addressing Vista‘s cross-motions for summary judgment. In its brief, the Division takes no position with respect to Vista‘s remaining issues in the view that these concern equitable monetary claims that fall outside the Division‘s exclusive jurisdiction. But in the event this Court determines that the district court could not properly grant such relief without reaching Vista‘s ultimate entitlement to stop-loss reimbursement, the Division conditionally asserts that the courts would lack jurisdiction to adjudicate those issues until administrative remedies are exhausted.
Vista‘s motions for summary judgment
Because Vista‘s third issue seeks summary judgments affirming some of the administrative orders, it logically precedes Vista‘s other appellate issues in the 20 cases to which it applies. Accordingly, we will address it first. We review the district court‘s summary-judgment rulings de novo. Valence Operating Co. v. Dorsett, 164 S.W.3d 656, 661 (Tex.2005); Provident Life & Accident Ins. Co. v. Knott, 128 S.W.3d 211, 215 (Tex.2003). Summary judgment is proper when there are no disputed issues of material fact and the movant is entitled to judgment as a matter of law.
In each of its motions for summary judgment, Vista asserted that the administrative order being challenged by Texas Mutual must be affirmed as a matter of law, notwithstanding the ALJ‘s reliance on the erroneous threshold-only view of the stop-loss exception, because substantial evidence in the administrative record (itself a question of law18) supports a theory that, in Vista‘s view, effectively rendered the ALJ‘s error harmless or immaterial. Specifically, Vista urged that there was substantial evidence that Texas Mutual administratively waived its right to contest whether the hospital services were “unusually costly and unusually extensive.” Vista has reasoned that this asserted waiver by Texas Mutual amounted to a concession that the hospital services were “unusually costly and unusually extensive,” making the ALJ‘s unchallenged findings that the expenses met the $40,000 stop-loss threshold singularly sufficient to support the order even under a correct interpretation of the stop-loss exception.
In urging that the district court could disregard the ALJ‘s erroneous legal conclusions and findings predicated on the threshold-only view of the stop-loss exception, Vista invokes the longstanding principle—one that predates APA substantial-evidence review on the administrative record—that a reviewing court generally must affirm an administrative order “if it is correct on any theory of law applicable to the case,” regardless of whether the agency purported to rely on that legal theory or even relied on an erroneous one. See Gulf Land Co. v. Atlantic Ref. Co., 134 Tex. 59, 131 S.W.2d 73, 77 (1939). Howev
The closest Vista can come to such support is to refer us to the following legal conclusion contained in each administrative order:
Pursuant to
28 TAC § 133.307(j)(2) , any defense or reason for a denial of a claim not asserted by a carrier before a request for medical dispute resolution may not be considered at the hearing before SOAH, whether or not it arises out of an audit.
The cited rule, section 133.307(j)(2) of Texas Administrative Code title 28, limits the “defenses” or “denial reasons” that a carrier may raise in a medical-fee dispute-resolution proceeding before the Division solely to those the carrier “presented to the requestor prior to the date the request for medical dispute resolution was filed with the [D]ivision and the other party.” See
There is, in short, no indication in the respective administrative orders that the ALJ relied on any finding or conclusion that Texas Mutual had waived rights in regard to reimbursement payments, and the district court was not permitted to supply that rationale to support each order. See Gulf Land, 131 S.W.2d at 77-78; see also Yeary v. Board of Nurse Exam‘rs, 855 S.W.2d 236, 240-41 (Tex.App.-Austin 1993, no writ) (“In our review, we are limited to the factual grounds the [agency] actually gave as the basis for its conclusion of law, although we may affirm the order on a legal ground not mentioned by the [agency] in its final order,” and “[a]s to the factual grounds stated by the [agency] as the basis for its conclusion of law, ... we must judge the validity of the [agency‘s] order ‘by what it says.‘“) (citing Gulf Land, 131 S.W.2d at 84; Morgan, 498 S.W.2d at 152). And even if the legal conclusion Vista cites could be construed as an ultimate finding or conclusion adopting Vista‘s waiver theory, substantial evidence to support that finding would still be lacking because there are none of the underlying fact findings that would be necessary to demonstrate a reasonable basis for that ultimate finding or conclusion. See Charter Med.-Dallas, 665 S.W.2d at 453.
At the time an insurance carrier makes payment or denies payment on a medical bill, the insurance carrier shall send, in the form and manner prescribed by the [Division], the explanation of benefits to the appropriate parties. The explanation of benefits [EOB] shall include the correct payment exception codes required by the [Division‘s] instructions, and shall provide sufficient explanation to allow the sender to understand the reason(s) for the insurance carrier‘s actions. A generic statement that simply states a conclusion such as “not sufficiently documented” or other similar phrases with no further description of the reason for the reduction or denial does not satisfy the requirements of this section.
Former Rule 133.304(c). As Vista urges, the EOBs at issue are contained in the administrative record from each respective proceeding and their contents are uncontroverted. Vista reasons that the face of each EOB demonstrates that, as a matter of law, Texas Mutual failed to provide “sufficient explanation to allow [Vista] to understand the reason(s) for the insurance carrier‘s actions,” as Former Rule 133.304(c) requires, with respect to Texas Mutual‘s contention that the hospital services at issue were not “unusually costly and unusually extensive.” Leaving aside whether such a determination could in itself supply the necessary factual underpinnings for Vista‘s waiver theory,20 Vista fails to demonstrate that Texas Mutual‘s EOBs violated Former Rule 133.304(c).
Each EOB was printed on a Division-approved form and listed itemized charges that Vista had billed Texas Mutual in connection with a hospital admission. Beside each itemized charge was indicated Texas Mutual‘s payment on the charge, which in each instance was either zero or an amount reduced below the amount charged. Accompanying each charge and payment reference was indicated “exception code F.” Vista‘s summary-judgment evidence established that the Division had adopted 22 “exception codes” and directed that exception code F—which the Division titled or described as “Fee guideline MAR [Maximum Allowable Reimbursement] reduction“—was to be used “when the [carrier] is reducing payment from the billed amount in accordance with the appropriate [Division] fee guideline‘s MAR ... [and] NOT to be used for reductions based on lack of documentation or for charges for which [the Division] has not established an MAR.” A complete listing or glossary of the 22 exception codes and their brief descriptions was also incorporated into the EOB form. Consequently, a reader of the form can discern that Texas Mutual‘s references to exception code F meant “Fee guideline MAR.” Alongside each refer-
Although Vista does not appear to quarrel with whether “F” was the appropriate exception code for Texas Mutual to use under the circumstances here, see Former Rule 133.304(c), it urges that Texas Mutual‘s references to “Fee guideline MAR reduction” and “THE CHARGE FOR THE PROCEDURE EXCEEDS THE AMOUNT INDICATED IN THE FEE SCHEDULE” amounted only to the sort of “generic statement[s] that simply state a conclusion” that Former Rule 133.304(c) prohibits, and did not satisfy the rule‘s requirement of a “sufficient explanation to allow the sender to understand the reason(s) for the insurance carrier‘s actions.” See id. Vista also contrasts these references with more specific explanations that Texas Mutual included in the “negative” EOBs it generated in connection with its refund requests,21 suggesting this is tantamount to an admission by Texas Mutual that its earlier EOBs were deficient. However, the Division has adopted a construction of Former Rule 133.304(c)‘s requirements that is less exacting than the standard Vista advocates, and we conclude that we should defer to it.
The Division refers us to several of its medical-fee dispute decisions involving stop-loss issues—some of which have involved Vista—that have addressed whether EOBs materially identical to Texas Mutual‘s here satisfy Former Rule 133.304(c)‘s requirement. In these decisions, the Division uniformly held that EOBs citing explanation code “F” (“Fee Guideline MAR reduction“) coupled with a reference to “fee schedules” or similar shorthand “support an explanation for the reduction of reimbursement” from the stop-loss amount to the per diem rates and “provide sufficient explanation to allow the provider to understand the reason(s) for the insurance carrier‘s action(s).”22
The Division has requested that we take judicial notice of these administrative decisions. Vista has not objected. We will do so. See Office of Pub. Util. Counsel v. Public Util. Comm‘n, 878 S.W.2d 598, 600 (Tex.1994) (holding that court of appeals must take judicial notice of agency‘s published order if asked to do so) (citing
We conclude that Former Rule 133.304(c) is sufficiently vague, ambiguous, and open to policy interpretation with respect to the precise parameters of a “sufficient explanation to allow the sender to understand the reason(s) for the insurance carrier‘s actions,” as distinguished from a “generic statement,” that we should defer to the Division‘s construction of these terms if it is reasonable and not plainly erroneous or inconsistent with the rule‘s text. See id. We further conclude that the Division‘s construction is reasonable, not plainly erroneous, and not inconsistent with the rule‘s text, but is instead within the range of reasonable constructions permitted by that language. See id. Accordingly, we give deference to the Division‘s construction. See id.
Texas Mutual‘s EOBs plainly pass muster under the Division‘s construction of Former Rule 133.304(c). Again, Texas Mutual‘s EOBs are materially identical to those addressed in the administrative decisions to which the Division refers us. Consequently, the Texas Mutual EOBs that Vista cites as conclusive proof of its waiver theory instead only further demonstrate the absence of substantial evidence to support it. See
Absent administrative findings, conclusions, and substantial evidence to support Vista‘s waiver theory, the district court did not err in denying Vista‘s motions for summary judgment. We overrule Vista‘s third issue.
Vista‘s challenges to monetary relief
Having overruled Vista‘s sole issue that would support affirming any of the administrative orders, we now turn to Vista‘s issues challenging the monetary relief the district court awarded upon reversing those orders. Vista‘s principal contention, advanced chiefly within its first issue, is that the district court lacked subject-matter jurisdiction to award the monetary relief because it amounted to the sort of “refund” of an “overpayment” of medical reimbursement to which the Division (and, in turn, SOAH) have been vested with exclusive jurisdiction to determine entitlement, subject to judicial review. Because Vista‘s arguments and Texas Mutual‘s responses are grounded in the principles that govern analysis of administrative-agency jurisdiction, and that of the Division in particular, it is helpful to first summarize those principles before turning to the parties’ specific assertions regarding them.
Our “analytical starting point” with such issues is Article V, section 8 of the Texas Constitution, which provides that a district court‘s 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 contrast, “there is no presumption that administrative agencies are authorized to resolve disputes. Rather, they may exercise only those powers the law, in clear and express statutory language, confers upon them.” Subaru, 84 S.W.3d at 220. “Courts will not imply additional authority to agencies, nor may agencies create for themselves any excess powers.” Id. The courts are not divested by an agency of the subject-matter jurisdiction they would otherwise possess to adjudicate a cause except if and to the extent the Legislature has granted the agency exclusive jurisdiction, or the sole power to make an initial determination of a claim or issue. See id. at 221; Apollo, 301 S.W.3d at 859. Whether the Legislature has done so is determined by examination and construction of the relevant statutory scheme, and is thus a question of law that we review de novo. See Thomas v. Long, 207 S.W.3d 334, 340 (Tex.2006) (citing Su-
As previously noted, and as all parties acknowledge, the Legislature has impliedly delegated exclusive jurisdiction to the Division (and, in turn, SOAH) to determine, subject to judicial review, medical-fee disputes—i.e., “disputes over the amount of payment due for services determined to be medically necessary and appropriate for treatment of a compensable injury” that must be paid by workers’ compensation insurance carriers to reimburse health care providers for “medical benefits” provided to injured workers. See
162 S.W.3d at 263-67; Howell, 143 S.W.3d at 435-36. This jurisdiction has been held to be implicated by any claim, even if couched in common-law or equitable theories of recovery, through which a health-care provider seeks relief predicated on an asserted entitlement to medical reimbursement under the workers’ compensation act and Division rules. See Howell, 143 S.W.3d at 438. In essence, this holding is an application of the rationale underlying the Texas Supreme Court‘s Fodge decision, which held that common-law claims by injured workers that would have the effect of establishing a right to workers’ compensation benefits implicate the Division‘s exclusive jurisdiction to award such benefits, and thus cannot be litigated unless and until those administrative remedies are first exhausted. See American Motorists Ins. Co. v. Fodge, 63 S.W.3d 801, 803 (Tex.2001).
In Apollo, we held that this jurisdiction was similarly implicated by tort claims asserted against a benefits management company (an entity that assists carriers in processing and paying reimbursement claims) by an assignee of a health-care provider‘s reimbursement rights, to the extent the claims required determination of the amount of reimbursement that was properly owed by the carrier to the provider under the act and Division rules. See Apollo, 301 S.W.3d at 862-71. And in Eckerd, we held that the Division‘s exclusive jurisdiction over medical-fee disputes was likewise implicated by a workers’ compensation carrier‘s claims seeking to recover “overpayments” of reimbursement to a provider beyond the amounts the carrier is obligated to pay under the workers’ compensation act and rules. See Eckerd, 162 S.W.3d at 263-67. The specific claims we addressed in Eckerd, it so happens, were asserted by Texas Mutual, and sought to recover alleged past “overpayments” under legal theories that included money had
In concluding that the Legislature intended for the Division‘s medical-fee dispute-resolution processes to serve as the sole means of obtaining the determination—necessary for recovery in each of these cases—as to the proper amount of reimbursement the carrier owed the provider under the act and Division rules, we cited three basic features of the workers’ compensation act. First, we emphasized that a health care provider‘s entitlement to any particular amount of reimbursement payment and a carrier‘s corresponding obligation to pay that amount derive from the workers’ compensation act rather than the common law. See Apollo, 301 S.W.3d at 866-67; Eckerd, 162 S.W.3d at 266; cf. Cash Am., 35 S.W.3d at 15-17. Second, we noted the “pervasive” and “comprehensive” nature of the workers’ compensation act‘s regulatory scheme, and its governance of medical reimbursement in particular. See Apollo, 301 S.W.3d at 860; Eckerd, 162 S.W.3d at 264-66; Howell, 143 S.W.3d at 435-38. Third, we emphasized that the Legislature has provided specific adjudicatory mechanisms and remedies by which the Division could determine and enforce the respective rights of providers and carriers regarding medical reimbursement. See Apollo, 301 S.W.3d at 860-61; Eckerd, 162 S.W.3d at 265, 266 n. 12; Howell, 143 S.W.3d at 435-38. In Eckerd, for example, we observed that the act and Division rules provided mechanisms for resolving disputes between providers and carriers regarding the proper amount of reimbursement due, 162 S.W.3d at 265 & n. 9, empowered the Division to grant administrative remedies that we deemed equivalent to the common-law remedies Texas Mutual was pursuing—including ordering “refunds” under Labor Code sec
On the other hand, we have also recognized that not every claim related to medical reimbursement presents a medical-fee dispute and falls within the Division‘s exclusive jurisdiction. As we explained in Apollo, “[w]hat matters” with regard to the Division‘s exclusive jurisdiction over medical-fee disputes “is whether the claims are based on the alleged failure of carriers to pay ... in compliance with the statutes and rules governing ... fee reimbursement,” whether by underpayment or overpayment, such that adjudication would require determination of the specific amount due under those standards and thereby infringe the Division‘s sole power to initially determine those issues. See id. at 865; cf. Fodge, 63 S.W.3d at 803. Although we concluded that two of the claims at issue in Apollo were predicated on alleged entitlements to particular amounts of reimbursement due from a carrier, thereby presenting medical-fee disputes, we held that two other claims did not because they presumed the carrier had paid the correct amount of reimbursement due under the act and rules and complained only that the defendant had acted wrongfully in depriving the plaintiff the opportunity to establish an entitlement to greater reimbursement. See Apollo, 301 S.W.3d at 867-69. A parallel distinction is recognized in the progeny of Fodge, which have distinguished between claims by injured workers that would have the effect of establishing a right to workers’ compensation benefits, thereby infringing the Division‘s exclusive jurisdiction to award such benefits, and claims that did not seek such benefits or presumed the absence of workers’ compensation coverage, which have been held to be beyond the Division‘s jurisdiction to decide.24
In Apollo, we further held that those two claims did not present a medical-fee dispute or otherwise fall within the Division‘s exclusive jurisdiction merely because the plaintiff sought damages predicated on the reimbursement amounts that a carrier
The parties’ competing contentions regarding the district court‘s jurisdiction here distill down essentially to whether Texas Mutual‘s claims for monetary relief are materially identical to its claims in Eckerd, as Vista suggests, or are more closely akin to the two claims in Apollo that were held not to present medical-fee disputes, as Texas Mutual insists. In support of its view, Vista urges that Texas Mutual‘s monetary claims fall squarely within the scope of act provisions and Division rules that authorize carriers to obtain “refunds” of reimbursement paid in excess of amounts properly owed under the act and Division rules. Vista emphasizes Labor Code section 413.016(a), which mandates that the Division “shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or fee guidelines.” See
Drawing on our reasoning in Eckerd, Apollo, and Howell, Vista adds that the Legislature‘s provision of these administrative remedies, viewed in the context of the workers’ compensation act‘s “pervasive regulatory scheme,” reflects its intent that the remedies serve as the sole means by which Texas Mutual can recover any excess payment of medical reimbursement it made to Vista. See Apollo, 301 S.W.3d at 860; Eckerd, 162 S.W.3d at 264-66; Howell, 143 S.W.3d at 435-38. In other words, according to Vista, Texas Mutual can obtain recovery or “refunds” of additional reimbursement it paid under the now-invalidated administrative orders only if it litigates, and ultimately defeats, Vista‘s claim for stop-loss reimbursement—now remanded to the Division, and yet to be resolved—through the Division‘s medical dispute-resolution process. This statutory scheme, Vista insists, divests the district court of any subject-matter jurisdiction to award Texas Mutual the monetary relief challenged here.
In response, Texas Mutual acknowledges that its claims here can be said to seek a type of “refund” of reimbursement it contends it does not properly owe Vista under the 1997 hospital fee guidelines—indeed, it has used the term “refund” throughout this litigation to describe the relief it seeks—and that the Division is empowered to provide such “refunds” under Labor Code section 413.016(a). But Texas Mutual questions whether the Division‘s rules governing medical-fee disputes contemplate “refund” claims arising, as do its claims here, from the payment of additional reimbursement in compliance with an administrative order in a medical-fee dispute that is later reversed, as opposed
More broadly, Texas Mutual insists that the mere existence of an administrative “refund” remedy does not in itself suffice to establish legislative intent to supplant the district court‘s jurisdiction to grant the monetary relief it awarded here. Why this is so, Texas Mutual reasons, begins with a conceptual distinction between an “ultimate” determination of Vista‘s entitlement to stop-loss reimbursement, which is the focus of the Division‘s medical-fee dispute-resolution processes, and what the carrier views as the focus of the theory of recovery on which the judgment awards were based—money had and received.
An action for money had and received is equitable in nature and belongs conceptually to the doctrine of unjust enrichment. See Best Buy Co. v. Barrera, 248 S.W.3d 160, 162 (Tex.2007) (per curiam); Edwards v. Mid-Continent Office Dist., L.P., 252 S.W.3d 833, 837 (Tex.App.-Dallas 2008, pet. denied) (quoting Amoco Prod. Co. v. Smith, 946 S.W.2d 162, 164 (Tex.App.-El Paso 1997, no writ)). The doctrine of unjust enrichment characterizes the result of a failure to make restitution under circumstances that give rise to an implied or quasi-contractual obligation to return those benefits. See Edwards, 252 S.W.3d at 837 (citing Amoco, 946 S.W.2d at 164). An action for restitution via money had and received is said to lie whenever the defendant holds money that “in equity and good conscience” “belongs” to the plaintiff “under the particular circumstances of each case.” Best Buy, 248 S.W.3d at 162; Staats v. Miller, 150 Tex. 581, 243 S.W.2d 686, 687 (1951); see also id. (also describing the standard as “to which party does the money, in equity, justice, and law, belong“). The action is not premised on wrongdoing, but rather “aims at the abstract justice of the case, and looks solely to the inquiry whether the defendant holds money, which ... belongs to the plaintiff.” Staats, 243 S.W.2d at 687-88 (quoting United States v. Jefferson Elec. Mfg. Co., 291 U.S. 386, 403 (1934)). It has also been said that “a cause of action for money had and received is ‘less restricted and fettered by technical rules and formalities than any other form of action.‘” Id. at 687 (quoting Jefferson, 291 U.S. at 402-03).
In support of summary judgment on its money-had-and-received claims, Texas Mutual has asserted that the disputed funds “belong” to it in “equity and good conscience” because the 1997 hospital fee guideline presumes per diem reimbursement and that, as of the time of the district court judgments below, Vista has no valid order entitling it to the higher stop-loss payments. In essence, Texas Mutual has argued that unless and until Vista can show itself entitled to stop-loss reimbursement on remand, the equities weigh in favor of returning the disputed additional reimbursement to the carrier, thereby returning it to the same economic position in which it would have been had the funds never been awarded or paid to Vista in the first place. Relatedly, Texas Mutual has relied on longstanding precedent holding that these equitable principles generally require that a party who had received payment under a judgment that is subse
Whether it is entitled to recover the disputed funds in “equity and good conscience,” in Texas Mutual‘s view, does not require a determination of Vista‘s entitlement to stop-loss reimbursement, the sine qua non of medical-fee disputes. See Apollo, 301 S.W.3d at 865. Texas Mutual similarly distinguishes its money-had-and-received theory on the basis that it goes only to whether it or Vista should be entitled to hold the disputed funds now, in the interim pending the “ultimate” determination of Vista‘s entitlement to stop-loss reimbursement, and does not implicate the Division‘s exclusive jurisdiction to initially determine that ultimate issue. Further, because its money-had-and-received claims are rooted in equitable and common-law principles rather than the workers’ compensation act, Texas Mutual reasons, we should not construe the workers’ compensation act to deprive them of this remedy absent “clear expression” of such legislative intent. See Cash America, 35 S.W.3d at 16. That required “clear expression” of legislative intent is lacking, Texas Mutual suggests, because the workers’ compensation act does not address or purport to supplant judicial power to award interim relief like the district court fashioned here, if indeed the act addresses “refunds” or other relief for carriers in Texas Mutual‘s situation at all.
To resolve the jurisdictional issue, we consider first whether the workers’ compensation act provides any administrative remedy through which an insurance carrier in Texas Mutual‘s position, one that has paid additional reimbursement to comply with an administrative order in a medical-fee dispute that is ultimately reversed on judicial review, can potentially recoup those funds. See Apollo, 301 S.W.3d at 870. Assuming that it does, the next question is whether the Legislature intended that remedy to serve as the sole and exclusive means for Texas Mutual to recover the additional reimbursement, to the extent of divesting the district courts of any jurisdiction they might otherwise possess to award the monetary relief at issue here. We conclude that both questions must be answered in the affirmative.
The parties concur that section 413.016(a) would provide a remedy through which a carrier in Texas Mutual‘s situation could seek refunds of alleged overpayments, and we agree. We find it significant that the Legislature did not place any limitations or qualifications on the circumstance under which a carrier would come to pay “charges ... to a health care provider in excess of those allowed by the medical policies or fee guidelines,” so as to require the Division to order a “refund.” See
The Legislature has crafted a medical-fee dispute-resolution regime under which (1) the Division initially determines the amount of reimbursement owed by a carri
This statutory regime anticipates and provides a procedural mechanism for determining whether “charges [were] paid to a health care provider in excess of those allowed by the medical policies or fee guidelines,” as a predicate to refund relief under section 413.016(a). Namely, upon reversal of the administrative orders, the APA required the district court to remand Vista‘s claims for stop-loss reimbursement for redetermination, through the medical-fee dispute-resolution process before the Division (and possibly SOAH, and then judicial review in district court), under a correct, threshold-plus construction of the stop-loss exception. See
Assuming the existence of this refund remedy under section 413.016(a), Texas Mutual seems to acknowledge that if it were to pursue “refunds” or recovery of the additional reimbursement it paid Vista predicated on a determination that Vista did not satisfy the requirements of the stop-loss exception, those claims would be medical-fee disputes within the Division‘s exclusive jurisdiction. See Eckerd, 162 S.W.3d at 263-67.27 In insisting that its money-had-and-received claims do not implicate the Division‘s exclusive jurisdiction, Texas Mutual ultimately relies on asserted conceptual distinctions between the timing of the relief sought (interim immediate judicial relief versus relief whenever Vista‘s claims to stop-loss reimbursement are finally determined) and the legal theories presented (who in “equity and good conscience” should be deemed to “own” the funds now versus whether Vista qualifies for stop-loss reimbursement under a correct application of the stop-loss exception).28 We conclude that these conceptual distinctions were of no moment to the Legislature when enacting the workers’ compensation act, and that it instead intended the medical-fee dispute-resolution process to supplant judicial jurisdiction to award relief like the district court provided here. We reach this conclusion for three basic reasons.
First, although Texas Mutual strives to portray its money-had-and-received claims as being rooted solely in equity or the common law, the claims instead seek redress for alleged injury that derives from the workers’ compensation act—medical reimbursement Texas Mutual paid to Vista in excess of the amounts to which the carrier claims the provider is properly entitled under the act and Division rules. While Texas Mutual attempts to distinguish between an “ultimate” determination of Vista‘s entitlement to stop-loss reimbursement versus a determination of whether Vista should get to keep the stop-loss reimbursement it was paid under the
The second reason, to which we have already alluded, is that the Legislature intended the workers’ compensation act to serve as a “pervasive” and “comprehensive” scheme governing the provision of benefits to injured workers, including the manner in which health care providers are compensated for providing services within that system. See, e.g., id. at 860; Eckerd, 162 S.W.3d at 264-66; Howell, 143 S.W.3d at 435-38. Each feature of that scheme reflects painstaking Legislative economic and policy judgments as to the appropriate means of balancing the often-competing interests of participants to achieve a viable compensation system within constitutional limitations. See, e.g., Mid-Century, 187 S.W.3d at 758. In the context of this comprehensive statutory framework, it seems doubtful that the Legislature intended to leave the courts free to fashion “interim” monetary relief between parties to pending medical-fee disputes, so long as the relief purported to avoid the “ultimate” question of the proper amount of reimbursement that is owed.29
This observation brings us to the third reason why we conclude the Legislature intended the section 413.016(a) refund remedy to supplant such “interim” judicial relief, which is closely related to the second: Texas Mutual‘s view would invite disruptions to the workers’ compensation act‘s careful balancing of interests that the Legislature could not possibly have intended. See Great-West Life & Annuity Ins. Co. v. Texas Attorney Gen. Child Support Div., 331 S.W.3d 884, 899 (Tex.App.-Austin 2011, pet. denied); see also
We hold that Texas Mutual‘s sole remedy for recovering medical reimbursement it paid to Vista under the administrative orders reversed by the district court lies in the Division (and, in turn, SOAH), subject only to judicial review under the APA, and that the district court lacked subject-matter jurisdiction to award those funds to Texas Mutual in the judgments. Accordingly, we sustain Vista‘s first issue, reverse the judgment awards of monetary relief, and render judgment dismissing Texas Mutual‘s money-had-and-received claims for want of jurisdiction.
Our disposition of Vista‘s first issue makes it unnecessary for us to reach its second and fourth issues, which present other challenges to the district court‘s judgment awarding monetary relief on Texas Mutual‘s money-had-and-received claims. See
In response, Vista asserts that Texas Mutual is seeking relief more favorable than that afforded it in the judgment and, consequently, was required to perfect its own appeal in order to raise its complaint. See
Assuming without deciding that Texas Mutual preserved this complaint for appellate review, we would hold that, in the absence of further support in the APA‘s text or Texas Supreme Court precedent telling us otherwise, the APA does not authorize the monetary relief Texas Mutual seeks. We overrule Texas Mutual‘s cross-point.
CONCLUSION
In light of our disposition of the parties’ issues, we affirm the district court‘s judgments reversing the administrative orders and remanding Vista‘s claims for stop-loss reimbursement to the Division for further proceedings. We reverse the district court‘s judgments awarding Texas Mutual monetary relief and render judgments dismissing those claims for want of jurisdiction. However, because Texas Mutual has asserted alternative constitutional and statutory claims that may not be directly
Shannon L. JOHNSON and Javier G. Gonzalez, Appellants
v.
WATERS AT ELM CREEK L.L.C., Appellee.
No. 04-12-00779-CV.
Court of Appeals of Texas, San Antonio.
Oct. 16, 2013.