Articles Posted in Public Benefits

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Shamrock Psychiatric Clinic, P.A., a Medicaid provider, was entitled to a contested-case hearing on the merits of the State’s claim to recoup alleged overpayments. Texas law directs the Inspector General to recover from a Medicaid provider any “overpayment” identified in a fraud or abuse investigation. Here, Shamrock received a “Notice of Payment Hold." Shamrock requested an expedited administrative hearing. Shamrock later received a “Final Notice of Overpayment.” The parties agreed to consolidate the payment hold and overpayment issues into one proceeding. The administrative law judge (ALJ) dismissed the overpayment and payment-hold cases due to Shamrock’s failure to submit a timely written request for an appeal. Shamrock filed suit. The trial court granted the Inspector General’s plea to the jurisdiction on sovereign immunity grounds. Shamrock appealed, arguing that the ALJ and Inspector General had a ministerial duty to abide by a Rule 11 agreement created by the parties’ communications and the Inspector General’s written representations. The court of appeals affirmed. The Supreme Court reversed, holding (1) the parties agreed that Shamrock would defend itself against the overpayment claims in a contested-cse hearing; (2) the ALJ failed to perform the purely ministerial act of enforcing the Rule 11 agreement; and (3) therefore, the ultra vires exception to sovereign immunity applied to Shamrock’s suit. View "Shamrock Psychiatric Clinic, P.A. v. Texas Department of Health & Human Services" on Justia Law

Posted in: Public Benefits

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In an earlier suit, fourteen Texas hospitals filed a declaratory relief action against the Texas Health and Human Services Commission and its Executive Commissioner (collectively HHSC), challenging a cutoff date used by HHSC to cap the collection of data used to calculate Medicaid reimbursement rates for inpatient services. The Supreme Court declared the cutoff-date rule invalid and enjoined its enforcement. The Court further remanded the cause to the district court, where the hospitals argued that the Court's judgment should apply retroactively to provide them a basis to reopen their earlier administrative appeals and to seek reimbursement for the underpayment of past Medicaid claims calculated under the invalid cutoff-date rule. The district court found in favor of the hospitals. The court of appeals reversed, determining that the injunction should only operate prospectively. The Supreme Court affirmed, holding that the court of appeals correctly concluded that the Court's earlier opinion and judgment did not purport to reopen past rate determinations or closed administrative proceedings. View "El Paso County Hosp. Dist. v. Tex. Health & Human Servs." on Justia Law

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Several hospitals (Hospitals) sued Aetna, Inc. and Aetna Health, Inc. (collectively Aetna) for allegedly violating the Prompt Pay Statute. Aetna provided a Medicare plan (Plan) through an HMO called NYLCare. It delegated the administration of its Plan to North American Medical Management of Texas (NAMM), a third-party administrator. IPA Management Services (Management Services) provided medical services to Plan enrollees. Management Services entered into contracts with the Hospitals to secure hospital services for the Plan employees. Aetna was not a party to these contracts. The Hospitals submitted hospital bills to NAMM for payment. After NAMM and Management Services became insolvent, Aetna de-delegated NAMM and assumed responsibility for processing and paying claims. However, Aetna instructed the Hospitals to continue submitting their bills to NAMM. The Hospitals argued that Aetna was liable for NAMM's failure to timely pay claims and was responsible for $13 million in outstanding bills. The trial court granted summary judgment for Aetna. The court of appeals affirmed, concluding that because the Hospitals entered into contracts with Management Services and not with Aetna directly, the Hospitals had no viable prompt-pay claim. The Supreme Court affirmed, holding that the lack of privity between the Hospitals and Aetna precluded the Hospitals' suit. View "Christus Health Gulf Coast v. Aetna, Inc." on Justia Law