Texas Workers Compen. v. Patient Adv. Of Tx

• Decision Date: 28 May 2004
• Docket Number: No. 02-0804.,02-0804.
• Citation: 136 S.W.3d 643
• Parties: TEXAS WORKERS' COMPENSATION COMMISSION, Petitioner, v. PATIENT ADVOCATES OF TEXAS and Allen J. Meril, M.D., Respondents.
• Court: Texas Supreme Court

136 S.W.3d 643

TEXAS WORKERS' COMPENSATION COMMISSION, Petitioner, v. PATIENT ADVOCATES OF TEXAS and Allen J. Meril, M.D., Respondents.

No. 02-0804.

Supreme Court of Texas.

Argued September 11, 2003.

Decided May 28, 2004.

Thomas S. Leatherbury, Vinson & Elkins, L.L.P., Dallas, P.M. Schenkkan, Graves Dougherty Hearon & Moody, P.C., Austin, T. Daniel Hollaway, Hollaway & Gumbert, Houston, Phyllis B. Schunck, Clark Thomas & Winters, Austin, for Amicus Curiae.

Greg Abbott, Atty. Gen., Howard G. Baldwin, First Asst. Atty. Gen., Jeffrey S. Boyd, Thompson & Knight, Dewey E. Helmcamp III, Asst. Atty. Gen., Barry Ross McBee, Office of Atty. Gen., and Don Walker, Office of Atty. Gen., Austin, for Petitioner.

Bill Aleshire, M.D. Jennifer S. Riggs, Riggs & Aleshire, P.C., Austin, for Respondent.

Justice WAINWRIGHT delivered the opinion of the Court, in which Chief Justice PHILLIPS, Justice HECHT, Justice OWEN, Justice O'NEILL, Justice JEFFERSON, Justice SCHNEIDER, Justice SMITH, and Justice BRISTER joined.

In this case, we consider whether the Texas Workers' Compensation Commission (TWCC) substantially complied with the statutory requirements for adopting fee guidelines for medical treatments and services. We also decide whether TWCC exceeded its statutory authority to establish medical policies and guidelines by setting maximum amounts that health care providers may be reimbursed for certain medical services provided to injured workers. We consider whether TWCC's rules for performing audits and determining reimbursement amounts in the absence of specified fee guidelines improperly delegated the agency's audit and fee-setting authority to private entities and whether TWCC possessed the authority to limit the time within which a party may administratively dispute a claim. Finally, we address the constitutionality of the reimbursement guidelines and the time limitations TWCC established to bring an administrative dispute.

We hold that TWCC complied with the statutory requisites for promulgating the fee guidelines and acted within its designated powers in limiting specified medical fee reimbursements and the time to seek medical dispute resolution. We affirm the court of appeals' judgment on these issues. Because we conclude that TWCC did not delegate its power to private entities, we reverse the portion of the court of appeals' judgment that is contrary to this conclusion. We also overrule the constitutional challenge to TWCC's fee reimbursement guidelines and time limitations for commencing medical dispute resolution.

I. Factual and Procedural Background

In 1989, the Legislature enacted a new Workers' Compensation Act in response to rising medical costs and increasing insurance premiums.¹ Tex. Workers' Comp. Comm'n v. Garcia, 893 S.W.2d 504, 512-13 (Tex.1995). The Legislature created the Texas Workers' Compensation Commission and gave the agency broad powers to adopt rules necessary for the implementation and enforcement of the Workers' Compensation Act. Tex. Lab.Code § 402.061. One of TWCC's new functions was to establish fee guidelines for reimbursements to health care providers who treat injured workers. Id. § 413.011. To this end, the agency promulgated the Texas Workers' Compensation Commission Medical Fee Guideline 1996, adopted by reference in Rule 134.201 of the Texas Administrative Code. See 28 Tex. Admin. Code § 134.201 (indicating that copies of the Guideline may be obtained from TWCC's publication department). The Guideline contains the maximum allowable reimbursements (MARs) for thousands of medical procedures. The MARs establish upper limits on the amount of reimbursements payable to health care providers for the listed treatments or services. TWCC also promulgated a set of rules, now commonly referred to as the "Dispute and Audit Rules," which establish a process for insurance carriers to review and audit bills submitted by health care providers. Id. §§ 133.301-.305.² The rules also set up dispute resolution procedures to resolve disagreements over the necessity of medical procedures and the amount of reimbursements. Id. § 133.305. Requests for medical dispute resolution must be filed not later than one year from the date of the medical service. Id. § 133.305(d).

TWCC's adoption of the Guideline and the Dispute and Audit Rules are at the base of this dispute. Patient Advocates of Texas and Allen J. Meril, M.D. (collectively PAT) initiated this lawsuit claiming that TWCC did not follow the rulemaking procedures required by statute when promulgating the Guideline. Additionally, PAT asserts that TWCC exceeded its rulemaking authority by setting a ceiling on many medical fee reimbursements and limiting the time for a party to seek medical dispute resolution to one year from the date the medical service was provided. PAT also challenges the validity of the Dispute and Audit Rules alleging that TWCC illegally delegated its audit and fee-setting authority to private insurance carriers. Lastly, PAT raises constitutional challenges to the rules on the grounds that the MARs and the one-year time limitation constitute a taking of their property without due process and just compensation. In response, TWCC argues that its enactment of the Guideline meets statutory procedural requirements and the limits placed on medical payments are consistent with the agency's authority to establish medical policies and guidelines pursuant to section 413.011 of the Labor Code. TWCC claims that it retains its power to audit workers' compensation participants and establish medical fees, and that the Dispute and Audit Rules are simply a means to facilitate insurance carriers' review of the medical claims submitted by health care providers.

The parties filed cross-motions for summary judgment. The trial court rendered a final judgment in favor of TWCC, denying PAT's motion for summary judgment. The court of appeals affirmed in part and reversed in part, holding that TWCC impermissibly delegated its audit authority to private insurance carriers, and therefore, did not rule on the constitutional challenge to the Dispute and Audit Rules. 80 S.W.3d 66, 81. The court of appeals upheld the remaining portions of the summary judgment. Id. Both TWCC and PAT petitioned this Court for review.

II. Standard of Review

When both parties move for summary judgment and the trial court grants one motion and denies the other, the reviewing court should review the summary judgment evidence presented by both sides and determine all questions presented and render the judgment the trial court should have rendered. FM Props. Operating Co. v. City of Austin, 22 S.W.3d 868, 872 (Tex. 2000). The reviewing court must affirm summary judgment if any of the summary judgment grounds are meritorious. FM Props., 22 S.W.3d at 872; Star-Telegram, Inc. v. Doe, 915 S.W.2d 471, 473 (Tex. 1995). We now turn to the evidence presented by TWCC and PAT and consider whether summary judgment was properly granted.

III. The Medical Fee Guideline

PAT argues that the version of the Medical Fee Guideline that TWCC adopted is invalid because TWCC did not substantially comply with the rulemaking procedures set forth under certain provisions of the Administrative Procedure Act (APA). Tex. Gov't Code § 2001.002 (1996).³ Specifically, PAT alleges that TWCC (1) failed to comply with section 2001.033(1) of the APA by not including a reasoned justification for the Guideline; (2) failed to comply with section 2001.023(a) by not republishing the Guideline after amending it; (3) failed to comply with section 2002.014 by not making a copy of the proposed rule available to the public; and (4) failed to comply with section 2001.030 by not providing a statement of reasons for or against adopting the Guideline. For the reasons stated below, we affirm the court of appeals' judgment overruling PAT's procedural challenges to TWCC's enactment of the Guideline. See 80 S.W.3d at 75.

A. Reasoned Justification

The APA requires an administrative agency to provide a reasoned justification for a rule it promulgates in the order adopting it. Tex. Gov't Code § 2001.033(1). That is, the order must include how and why the agency reached the conclusions it did for adopting the rule, and the conclusions must be presented in a relatively clear, precise, and logical fashion. Nat'l Ass'n of Indep. Insurers v. Tex. Dep't of Ins., 925 S.W.2d 667, 669 (Tex. 1996). The order also must provide (1) a summary of the comments received from interested parties; (2) a restatement of the factual basis for the rule; and (3) the reasons why the agency disagrees with the comments. Tex. Gov't Code § 2001.033(1)(A)-(C); Nat'l Ass'n of Indep. Insurers, 925 S.W.2d at 669. If an order fails to substantially comply with these requirements, the rule is invalid. Tex. Gov't Code § 2001.035(a); Nat'l Ass'n of Indep. Insurers, 925 S.W.2d at 669. Requiring an agency to demonstrate a rational connection between the facts before it and the agency's rules promotes public accountability and facilitates judicial review. Nat'l Ass'n of Indep. Insurers, 925 S.W.2d at 669.

In the order adopting Rule 134.201, TWCC provided its reasons for enacting the Guideline. 21 Tex. Reg. 2361-92 (1996). Among other things, TWCC explained that based on an extensive national study by the Workers' Compensation Research Institute comparing fee reimbursement systems of twenty-seven states, Texas's workers' compensation system's reimbursements for specified procedures significantly exceeded the national median. 21 Tex. Reg. at 2362. TWCC's own analysis confirmed this conclusion. Id. TWCC enacted the Guideline "to move Texas towards a median cost position in comparison with other states and towards a market based system which reimburses based on values set by the market for [medical] procedures...." Id. TWCC also explained its rationale for adopting statewide rates instead of utilizing regional MARs. Id. The agency's analysis found that the minimal overall...