Tex. Med. Res., LLP v. Molina Healthcare of Tex., Inc.

• Decision Date: 23 February 2021
• Docket Number: No. 05-19-01447-CV,05-19-01447-CV
• Citation: 620 S.W.3d 458
• Parties: TEXAS MEDICINE RESOURCES, LLP ; Texas Physician Resources, LLP; and Pediatric Emergency Medicine Group, LLP, Appellants v. MOLINA HEALTHCARE OF TEXAS, INC., Appellee
• Court: Texas Court of Appeals

620 S.W.3d 458

TEXAS MEDICINE RESOURCES, LLP ; Texas Physician Resources, LLP; and Pediatric Emergency Medicine Group, LLP, Appellants

v.MOLINA HEALTHCARE OF TEXAS, INC., Appellee

No. 05-19-01447-CV

Court of Appeals of Texas, Dallas.

Opinion Filed February 23, 2021

Robert M. Roach Jr., Daniel William Davis, Roach Newton L.L.P., Houston, for Appellants.

Jonathan M. Herman, The Herman Law Firm, Dallas, for Appellee.

Before Justices Schenck, Osborne, and Partida-Kipness

Opinion by Justice Schenck

Texas Medicine Resources, LLP, Texas Physician Resources, LLP, and Pediatric Emergency Medicine Group, LLC (collectively, "Physicians") appeal the trial court's order granting Molina Healthcare of Texas, Inc.'s ("Molina") plea to the jurisdiction. Physicians assert the trial court erred in dismissing their claims because they have standing to assert same and their complaints present a justiciable controversy. We affirm the trial court's order.

BACKGROUND

Physicians are medical provider groups composed of doctors who staff emergency departments at hospitals and freestanding emergency medical care centers. Physicians assert they provide emergency care without regard to patients' financial standing, whether the patients have healthcare coverage or—where the patient has coverage—whether the Physicians have contractual relationships with the patient's insurance carriers.

Molina is a Health Maintenance Organization ("HMO") that issues Health Insurance Exchange ("HIX") plans.¹ Physicians are "non-network physicians" relative to Molina, meaning there is no written contract establishing the rates which Molina will pay for emergency medical care Physicians provide to Molina's enrollees. Thus, pursuant to the emergency care statute applicable to HMOs, Molina is to "pay for emergency care performed by [Physicians] at the usual and customary rate."² TEX. INS. CODE § 1271.155(a).

Physicians claim to have provided emergency medical care to more than 3,800 patients enrolled in Molina's HIX plans between January 2017 and September 2018. They billed Molina for the services. Dissatisfied with the payments they received, Physicians sued Molina seeking judicial resolution of their claim that Molina's reimbursement regime under Medicare–Medicaid programs, as implemented through the federal Affordable Care Act and corresponding federal and state regulations, is inadequate. Specifically, Physicians urge that the rates fail to satisfy the obligation to pay the "usual and customary" rate for services under an administrative regulation that has been codified as section 1271.155 of the Texas Insurance Code. They go on to argue that section 1271.155 implies a private cause of action and, thus, a justiciable claim to be presented to lay jurors. This theory has not met success with other courts. Molina urges that the regulation and resulting legislation are part of a broader comprehensive regulatory regime that courts have uniformly held affords no private right of action and presents no justiciable issue, or both. In addition, Physicians claim they are entitled to recover the value of the services provided to Molina's HIX plan enrollees under the equitable theory of quantum meruit and seek a declaration that the jury's finding on the usual and customary rate will be the rate Molina pays Physicians in the future. Molina urges that these claims are all anchored in the same regulatory regime and, accordingly, present a nonjusticiable controversy.

Molina filed a plea to the jurisdiction asserting Physicians lack standing to assert claims under the emergency care statute, the unfair settlement practices statute and the prompt payment statute; that no direct relationship exists between Physicians and Molina to support a quantum meruit claim; and no justiciable controversy exists to support Physicians' claim for declaratory relief regarding future claims.

The trial court granted Molina's plea and dismissed Physicians' claims in their entirety. This appeal followed. For reasons that follow, we join our colleagues in federal courts in finding these claims to be nonjusticiable at this time. See Angelina Emergency Med. Assocs. PA v. Health Care Serv. Corp. , No. 3:18-CV-00425-X, 2020 WL 7259222, at *1–2, 6–8 (N.D. Tex. Dec. 10, 2020) ; Apollo MedFlight, LLC v. Bluecross Blueshield of Tex. , No. 2:18-CV-166-Z-BR, 2019 WL 4894263, at *2–3 (N.D. Tex. Oct. 4, 2019).

DISCUSSION

I. Standard of Review

A plea to the jurisdiction challenges a court's subject-matter jurisdiction to hear a case. Bland Indep. Sch. Dist. v. Blue , 34 S.W.3d 547, 554 (Tex. 2000). When, as in this case, the plea challenges the claimant's pleadings, we determine whether the claimant has pleaded facts that affirmatively demonstrate the trial court's jurisdiction, construing the pleadings liberally and in favor of the claimant. Tex. Ass'n of Bus. v. Tex. Air Control Bd. , 852 S.W.2d 440, 446 (Tex. 1993).

"Standing is a prerequisite to subject-matter jurisdiction, and subject-matter jurisdiction is essential to a court's power to decide a case." M.D. Anderson Cancer Ctr. v. Novak , 52 S.W.3d 704, 708 (Tex. 2001). Thus, a plea to the jurisdiction is a proper vehicle to challenge a plaintiff's standing to maintain suit. Vernco Constr., Inc. v. Nelson , 460 S.W.3d 145, 149 (Tex. 2015). Ripeness is also a component of subject-matter jurisdiction. Robinson v. Parker , 353 S.W.3d 753, 755 (Tex. 2011). In order for a claim to be ripe, there must be "a real and substantial controversy involving genuine conflict of tangible interests and not merely a theoretical dispute." Bonham State Bank v. Beadle , 907 S.W.2d 465, 467 (Tex. 1995). The plaintiff bears the burden to plead and establish facts affirmatively showing the court has subject-matter jurisdiction. Tex. Dep't of Parks & Wildlife v. Miranda , 133 S.W.3d 217, 225–26 (Tex. 2004) ; see also Bland , 34 S.W.3d at 554.

We review a trial court's ruling on a plea to the jurisdiction de novo. Miranda , 133 S.W.3d at 226. In our review, we construe the pleadings liberally in favor of the pleader and look to the pleader's intent to determine whether the facts alleged affirmatively demonstrate the trial court's jurisdiction to hear the cause. See id. If the pleadings affirmatively negate the existence of jurisdiction, then the trial court may grant the plea to the jurisdiction without allowing the plaintiffs an opportunity to amend. Id. at 227.

II. Physicians' Claim Molina Violated the Emergency Care Statute

In their first issue, Physicians urge the trial court erred in dismissing their claim seeking to enforce the payment obligation set forth in the emergency care statute, specifically section 1271.155 of the Texas Insurance Code. Section 1271.155 requires HMOs to "pay for emergency care performed by non-network physicians or providers at the usual and customary rate or at an agreed rate." INS. CODE § 1271.155(a).

When a private cause of action is alleged to derive from a statutory provision, as it is in this case, our duty is to ascertain the drafters' intent. Rocor Int'l, Inc. v. Nat'l Union Fire Ins. Co. of Pittsburgh, PA , 77 S.W.3d 253, 260 (Tex. 2002). The legislature can indicate its intent to create a private right of action either by including an express provision in the statutory text or through implication. Brown v. De La Cruz , 156 S.W.3d 560, 563 (Tex. 2004). Physicians concede that section 1271.155 does not expressly confer a private right of action but contend that it does so by implication because the requirement that the HMO make the payment directly to the physician or provider establishes the statute was enacted to benefit healthcare providers; and thus, claim Physicians, they are entitled to enforce the payment obligation. See INS. CODE § 1271.155(f). The statute, as it existed at the time Physicians provided medical services to Molina enrollees, did not contain a provision that HMOs pay the physician or provider directly. That provision, subsection (f) to section 1271.155, was enacted in 2019, after Physicians provided the services at issue in this case, and it applies to health care or medical services provided on and after January 1, 2020. Consequently, Physicians' reliance on direct payment language subsequently added to the statute is misguided.³

How Texas addresses issues concerning the availability of and payment for emergency medical services involves important policy considerations that are primarily for the legislature, not the courts. The unique bifurcated structure of the Texas court system calls for particular deference to legislative choices regarding the method of enforcement of Texas statutes. Brown , 156 S.W.3d at 566. The legislature may delegate enforcement to executive departments, administrative agencies, regulatory commissions, local governments and districts, as well as to the criminal or civil courts. Id. at 566–67. We are obligated by separation of powers principles to exercise restraint, strictly construe statutory enforcement schemes, and imply a private cause of action to enforce a statute only when the legislature's intent is clearly expressed from the language as written.⁴ Witkowski v. Brian, Fooshee & Yonge Props. , 181 S.W.3d 824, 831 (Tex. App.—Austin 2005, no pet.) (citing Brown , 156 S.W.3d at 567 ). Although in some cases it may be desirable to imply a private right of action to provide remedies thought to effectuate the purpose of the statute, ultimately we must determine whether the drafters intended to create such a private remedy. See Transamerica Mortg. Advisors, Inc. v. Lewis , 444 U.S. 11, 15–16, 100 S.Ct. 242, 62 L.Ed.2d 146 (1979) ; see also Brown , 156 S.W.3d at 567 (rejecting rule of "necessary implication" that provides when a legislative enforcement scheme fails to adequately protect intended beneficiaries, the courts must imply a cause of action to effectuate the statutory purposes); Linick v. Emp'rs Mut. Cas. Co. , 822 S.W.2d 297, 300 (Tex. App.—San Antonio 1991, no writ) (where intent of legis...