### TEXAS CO URT OF APPEALS, THIRD DISTRICT, AT AUSTIN

NO. 03

- 19

- 00137

- CV

Appellants, McAllen Hospitals, L.P. d/b/a McAllen Medical Center and d/b/a Edinburg

Regional Medical Center and d/b/a Edinburg Children's Hospital and d/b/a McAllen Heart

Hospital an d d/b/a South Texas Behavioral Health Center; Fort Duncan Medical Center;

Northwest Texas Healthcare System Inc.; and Laredo Regional Medical Center d/b/a

Doctor's Hospital of Laredo // Cross

- Appellants, Texas Health and Human Services

Commission and Texas Health and Human Services Commission

Office of Inspector General

v.

Appellees, Texas Health and Human Services Commission and Texas Health and Human

Services Commission Office of Inspector General // Cross

- Appellees, McAllen Hospitals,

L.P. d/b /a McAl le n Medical Center and d/b/a Edinburg Regional Medical Center and d/b/a

Edinburg Children's Hospital and d/b/a McAllen Heart Hospital and d/b/a South Texas

Behavioral Health Center; Fort Duncan Medical Center; Northwest Texas Healthcare

System Inc.; and La re do Regional Medical Center d/b/a Doctor's Hospital of Laredo

FROM THE 261ST DISTRICT COURT OF TRAVIS COUNTY

NO. D

- 1

- GN

- 10

- 002274, THE HONORABLE ORLINDA NARANJO, JUDGE PRESIDING

M E M O R A N D U M O P I N I O N

Appellants McA llen Hospital s, L

. P. ; Fort Duncan Medical Center; Nor thwest

Texas Heal th care System, Inc.; and Laredo Regional Medical Center ( collec tively, the

“ Hospitals ” ) sued the Texas Health and Human Services Commi s sio n ( HHSC) and its Office of

Inspector Gen eral ( OI G) a f ter the OIG s ought to recoup funds previously paid by HHSC to the

H osp itals for Medicaid reimbursement. I n part, the Hospitals sought a writ of mand amus to

comp el HHSC to (1) review the OIG ’ s decision in a formal administrative a ppea l and (2) reope n2

certa in cases w h er e HHSC and the OIG had concluded that the Hosp it als failed to p rovide a

complete medical recor d

. After the parties filed c o mpeting motion s for summary judgment on

the H ospi tal s ’ clai ms for m andamus re lief , the trial court granted summary jud gment i n fav or o f

HHSC and the OIG

, in part, and in favor of the Hospitals , in part. The H ospitals subsequently

filed a notice of appeal from the trial court ’ s summar y

- judgment order , and HHSC and the OIG

filed a notice of c ross

- appeal.

W e co nclude that the re co upm en t s a t issue are n ot s anc tions “ arising o ut of an

investi gation of fraud

, w ast e, or abu se ” under Rule 371.16 01 and that , conse quently, the trial

court did not err in granting summary judgment in favor o f HHS C and the O I G on t he H o s pitals ’

cla im to comp el HH SC to conduct a formal administrative hearing

. W e also conclude that the

trial court did no t err in granting summary judgment in favor of the Hospital s on the ir claim to

comp el HHSC to reopen certain cases

. Howeve r, be caus e the mandamus relief g rant ed by the

trial court fails to con form wit h the rel ief requested and with the record, we will modify the tria l

court ’ s summary

-

judgmen t order as to th i s relief and, a s m o d ifi ed, affi rm.

LEGAL BACKGRO U ND

Medicaid is a c o o pe rati ve federal

− state assistance progr a m that uses pu blic funds

to pay for hea l th c ar e services pro vided to needy rec ip ients

. Hawkins v. Dallas C nty Hosp. Dist.

,

1 50 S.W .3d 535, 537 (Tex. App.

— Aust in 2 004

, no pet. ) (c iting 42 U.S.C . §§ 1396

- 1396 w 5

(G ra n t s to States for Medical Assistance Pr o grams ) )

. HHSC administer s the T e x as Med icaid

Program

. See T ex. Gov ’ t Code § 531.02 1 ; T ex. Hum. Res. Code § 32.02 1

. The OIG is charged

with in v estigat ing f

rau d, w ast e, and abuse in t he Program

, and for enforcing st a t e la w s relating to

the provision of Medicaid in Texas

. Se e Tex. Gov ’ t Code § 531 .10 2 ; 1 Tex. Admin . Code3

§ 371. 3 ( HHSC, Purpose and Authorit y )

. 1 In g eneral, u nder th e Tex as Medicaid P rogra m,

healthcar e servic e pro vid er s enr oll ed in the P rogram provid e m edi call y n e cess ar y treatment to

eligible rec ipients an d then seek r eimb ursement for the cost of those se rvices by submit ting a

claim to HHSC

. See T ex. H um. Res. Code § § 32.0 29 , .0 38 ; see als o Texas Medic aid P r ov id er

Pr oce d u r e s M a n u a l ( current ve rsion a t http://www.tmh p.com )

.

Th e dispute in this c ase aris e s from a disagreement abo ut a process w ith in the

T e xas Medic a id P rogram known as the Tex a s Medica l R e view Program (TMRP ) a nd, mo re

specif ic a lly

, a bout the scope of the proced ural pr ote c tions affor ded to service providers under

TMRP

. 2 Th e TMR P is “ t he inp a tient hospit al utiliza tion re view p roce ss HHSC uses for h o s pitals

reim bu r sed by HHSC ’ s prospective payment system

. ” 1 Tex. Admin. Co de § 3 71. 1 ( 93) ( d e fi ning

“ TM RP ” )

. T he TM RP i s impl emented by the HHSC Utilization R e view Unit within the OI G

a nd is governed by Su b c hapter C of Chapter 371 of Ti tle 1 of the Texas Administrative Code. 3

See id. §§ 371 .200

-

. 216 ( Ut ili zat io n R evie w ).

Under S u b cha pter C, H HSC s elects ca ses for TM RP u ti li za t ion review “ by a

sta t isti c ally valid ra ndom sam pling methodology and/o r focused ca s e selection. ” Id. § 371.201.

1 All ci tation s to Title 1 of th e Texas Administrative Code are to rules promul gate d by

HHSC

. Because t h e relevant portion s of HHSC ru l es in e ff e ct at the time of the underlying

d i sp ute ha ve no t su bs tan tiv ely changed

, t he part ies have c ited to the curre nt version of the rules

in t h eir m otions for summary judg ment and in th e ir appellate briefing

. Accordingly, u nless

otherwise stat ed

, a ll citatio n s to t he Tex a s Administrative Code in t his op ini on are t o t he cur rent

ver s io n of th e r ules

.

2 State plans for utilizati on review are re q uir e d by federal law. See 42 C.F

. R. § § 4 5 6 .2

(st ate p lan r equirem ents) , .2 3 (post

- payment revi e w pr oces s ), .1 01 ( u til ization

- re view plan required

for i npa ti ent hospital s ervi ces )

. HHSC c o nducts th e TMRP in a ccorda nce with ap plicable f ederal

la w. See 1 T ex. A d min . Code § 371.200 (Inpati ent Hospit al R e view Ut il iza tion Review Program).

3 Ch apte r 3 71 of T it l e 1 of th e Te x a s Admini strative Code is titled “Me di caid and Oth e r

Hea lt h and H uman Service s Fraud and A buse P r ogram In te grity

. ” S ee id

. §§ 371.1

- .171 9

.4

Among other thi ngs, t he T MRP process require s HHSC to ev a lua te “ the medi ca l nec es sity of the

a dmission ” und erlyi ng a serv ice pr ov i d er ’ s c laim f or reimbursement

. Id. § 371.203( a)( 1). “ Fo r

purposes of the TM RP u tilization rev iews , medical nece s sity means the patient has a condition

requir in g t re atment tha t can be s af e ly pr ovide d on l y i n th e in p at ien t s ett ing. ” Id. In conduc tin g

t h i s ev al ua ti on

, “ HHSC reviews the comp lete me di cal re cord for the requested admissio n(s)

, ”

inclu ding e mer genc y room records, medical/surgical history and physical examination

, d is charg e

summar y, phys i ci ans ’ not es, lab repo rts

, diagnost ic and imagin g rep orts, path ol ogy r ep orts,

nurses ’ note s

, and the rapy notes. Id

. § 371.203(b). If HHSC co ncludes that t h e me d ical ser vi ces

could h ave been rendered on an outpa tient basis a nd t hat , c onsequently, in pa t ien t adm i ssion was

not medical ly necess ary, it notifi es t h e se rvice pro vi de r of the decision to retro spec tiv ely deny

the clai m and direct s the claims adminis tr a tor to re coup p ayme n t

. Se e i d. § 371.206( a ) (Denial s

and R ecoupments for TMRP, TEFRA Hospitals, and Facility

- Specific Per Die m Methodology

Reviews)

. A s to t he ser vic e pr o v ide r ’ s re cou rs e upo n re c ei v ing noti fi catio n of an “ adverse

d ecision regar din g medical necessity of ad mission ” from the Utilization R evi ew Unit

, Rule

371.208 of the Texas Adminis tr ative Code pr ovides :

[T ] he hospital may appeal to HHS C

. T h e wri tte n not i f icati on of adver se decisio n

s ets o ut th e r espons ible a rea a nd time fram e within which the appeal must be

receiv ed by HHSC . The Texas Medicaid Policy and P roc edure Manual provides

a dditi onal inf

ormation on th e appeal proc ess

.

Id

. § 37 1. 2 08 ( Appe al s Re late d to U tilization Re view Depa rtment Revi ew De cisions ) ; see also

Texas Medic aid Prov ider Proce d u r e s M a n u a l ( current version at http:/ /www.tmhp.com )

.5 PROCEDURA L BAC KGROU ND

Th e u nd i s pute d evidence i n th is c ase esta bl i she s t h at the Hosp itals are healthcare

servi ce provid ers en rolle d i n the T e x as Med ic a id Program

. I n February 2010, the Hosp it als

received a “ Notice of Admi ssio n De nial (s) ” from the U tili za tion Review U nit

. I n th e Notice

, th e

U t iliz ation Revie w Un it in fo r m ed th e Hosp i tals th at it had reviewed approx imate ly th ir ty

- six

rei m bursemen t cl aims pr eviously submitted by the H ospit al s and that the Unit had dete rmin ed

,

“ after review of the informati on contained in the me dical re cor d ( s)

, that the [ inp at ien t ]

a dm i ss io n (s) [o n wh ich the reimbursement clai m s were based]

. . . were not m edicall y necessa ry. ”

B ecause t he admi ssions had occur red years ea r l ier and beca use t he H ospitals had already been

reimbursed f

or the s ervi c es

, th e U t iliz ati on Review Unit al so inf ormed t he H osp it als that it was

processing “ [a]n a dmission de nial

. . . for ea ch adm iss ion ” an d that the payment on the claim s

would be re cou p ed. F inally , t he Notice advis e d the Hos pita ls that if they w ere diss atisfi ed wi t h

the U til izatio n Re view Unit ’ s d ecisi o n

, t h ey co uld submit a request for a written app eal

.

The Hospi tals s ubsequen tly a ppeal e d the denial and recoupm ent d ecisions t o

HHSC UR /M e dical App eal s (the “ Medical Appeals Unit ” ) , as prov i ded f or by Rule 371 .2 08 and

a s d irected by the Noti ce

. T h e Ho spit al s ’ a pp eal consisted of a written appeal s upporte d b y a

wr itten explanat ion as to w hy the inpa tient ser vices w ere me dic ally necessar y. As to each

admission , the Medical Appeals Unit uph eld t he U ti lization Rev i e w Unit ’ s d ecision to den y

the cla im an d reco up pay me nt

. As to three of the adm issions, the Me dica l App eals U nit

expl ained in it s written notification s to th e Hospitals that it was upholding the Utilization Review

Unit ’ s decision becaus e th e “ the documentation provided is incomp l e te a nd i ns u ffici ent. ” I n

a ddition

, t he notificat ion s info r med th e H o spitals t hat t he Me dical Appeals Unit ’ s “ determination

is the fin al administrativ e decision in your app ealed cas e. T heref ore

, i n accord ance with6

Med i cai d pr ogram pol ic i es a n d pr o cedure s

, thi s de te r mination i s n o w consi der ed final a nd the

ca se i s clo sed. ”

Desp ite the A pp eal U nit ’ s a ssertion o f finality

, t he Hosp itals s ent a letter t o the

OIG Man ager of Sanction s stating that t h ey wishe d to admin istr ati vely appeal the U til i za tion

Revi e w Uni t ’ s d e n ial and rec o up men t decision and request ing that th e OIG f o rward th eir appeal

to HH SC ’ s Appe als Divisi on for d o cketing

. The Medical Appeals Unit denied t he H ospit a ls ’

request by letter

. T he Medical Appeals Unit explain ed

, “ The adm i n istra tive r ules gove rni n g

ho s pita li za tion r eview a re l ocated at [ Te x as Admin ist rative C od e, Section ] 371.208. Your client

has a vailed it sel f o f its appe llate remedies and the re are no othe r availa b l e a ven ues f or a ppeal. ”

T he Hospital s subse q uen tly filed s uit agai n st HHSC and the OIG

, see k i n g i n part

man damu s r elief r e lated to the defendants ’ (1) refu sa l to forw ard the Hospital s ’ request for a

f or mal administr ativ e hearing for docketing and (2) denial of at l e as t some of th e Hospitals ’

c laims on the groun d that the Hospit a l s h ad provided a n “ i nc omplete and insu ffici ent ” medical

recor d

. 4 The Hosp itals subsequently f iled a traditional motion for summary judgm ent on th e ir

mand amus claims. In the ir motio n for summar y jud g ment

, the Ho sp itals ar gue d t h at they we re

e nti t led to ma nda mus re lief o n th e ir claim t o compel HHSC and the OIG to forwar d the

U tilization R e view Unit ’ s denial and recoupment d ecision to HHSC ’ s General Counsel for

docketin g b ecaus e, accordin g to the Hos pit al s

, they are entitled to a formal ad mi nistrati ve appeal

un d er wh at is n o w Rul e 371 .161 5

. See 1 Tex. Admin. Code § 3 71 .1 6 15 ( Appeals, f ormerly

4 The Hosp ital s also a sserted cl aims f or d eclara t ory relief a nd a lleged that the

defendan ts ’ act io n s constit u ted a taking wit hout du e process of la w and wi thout due c ourse of

law. HH SC and the OIG fil ed a plea to the ju risdict ion based on sovere ign im munity , which th e

tria l court gr an te d

. On appe a l, the A marillo C ourt of A ppe al s affirmed t he tr ial co urt ’ s

juri s dic tional r uling and di s m issa l a s to all of the Hos pital s ’ c laims with the e xc e ption of their

clai ms for man dam us reli ef. See McAllen Ho sp s

. v . Sue h s , 4 26 S .W.3d 30 4, 3 16

- 18 (Tex.

App.

— Amari llo 2014, no pet.)

.7

id. § § 371.1667, .1669). The Hospit als a lso a sserted in their mo tion t hat they wer e entitl ed to

m an damu s relie f as a m atter of law on their c l ai m to comp el HHS C and th e OIG to reop e n a ll

ma tters wh er e HHSC had de nied the Hospi tals ’ claim due to an in complete me dical record

without providing an o pportuni ty t o suppl ement th e record under Rule 371. 206 (a )( 2)

. See i d.

§ 371.206(a )( 2 ) (out lining ty pe s of TMRP denia ls , includ in g “ a tec hnic a l denia l ” “ w hen a

h osp it al fai ls to make the c omplete med ical record available for revie w ” )

. I n respo nse

, HHSC

and the OIG f

i led a c ross

- motion for su m mary judg men t

, asse rting that the H o sp itals ’ mand amu s

claims w er e premis ed o n an incorrec t constru c t ion o f HHSC ’ s a dmin istr ative rules and that

, as a

ma tter of law, the Hos pitals could not estab l ish t h at HHSC had failed to comply with any

min isteria l duty

.

The trial court s u bs equently sig n e d an ord er denyin g the H o s pi ta ls ’ moti on for

sum mar y judgment in pa r t an d g ra nt ing HHSC and the OIG ’ s c ross

- motion for summa ry

judgme nt i n pa r t. A s to t he Hosp ita ls ’ claim to comp el a fo rmal adminis trat iv e appe al , the trial

court g ranted summary jud gment in fav or of HH SC and the O IG

. As to t he Hosp ital s ’ c laim to

com p el H H SC to reo pen claims denied due to an incomplete medical record , the trial court

grante d summary judgment in f avo r of t he Ho s pitals. Th is appea l and c r o ss

- appeal foll ow ed.

S TANDARD OF REVIEW

Su mmary judgm ent is pr op er if the movant est ablis he s th at th e re a r e no genu ine

issues of material f

act an d that the movant is ent itled to judg ment a s a mat ter o f law. Tex. R.

Civ. P. 166 a( c)

. We review a trial court ’ s ruling o n a mot ion for su m mary judgmen t unde r a

d e no vo s t an dar d of re view. Lig htnin g Oil Co. v

. An a d a rko E&P O nsho r e, LL C , 520 S.W.3d 39,

45 (Tex. 2017)

. When bot h parties move for summar y judgment on o v e r lappin g issues and the8

trial court grant s one motion an d denie s the other, we consid e r the summar y

- judgmen t evi den ce

pre sented by bot h sides a nd d ete rm ine all que s tions presente d. Texas As s ’ n of Acupu ncture &

Or i ental Med. v. Texas Bd. of Chiropr acti c E xam ’ r s

, 524 S.W.3d 734, 738 (Tex. App.

— Aus tin

2017, no pe t. ) (c it ing Val ence Operatin g C o. v. Dorse tt , 1 64 S .W .3d 65 6, 66 1 (Tex. 20 05) )

. If

we de t e rmi n e that th e tr ial co urt erred, we render t he judgment the tr ial court should have

r ender ed. Valence , 164 S.W.3d at 661

.

T o the extent our appellate r eview requires u s to int erp ret HHSC ’ s rules

, we

r evi ew t he se quest ion s of law de novo. Cen ter Poi n t E nergy Ho us

. E lec

. , LLC v. P ub lic Util.

Co mm ’ n of Tex. , 408 S .W.3d 910, 916 (T ex. App.

— Austin 201 3, pet. denied) (ci ting R odriguez

v. Ser vi ce s Lloy ds Ins. , 9 97 S .W.2d 248, 25 4 (Tex. 1 999) )

. Because a d mi nis tr at ive rules ha ve

the s ame for ce and effect a s s tatute s

, we i nter p ret admini stra tive r ules us ing tra ditiona l pr inciples

of s tatutory constructi on. TGS

- NOP EC Geop hysica l Co. v. Combs , 340 S.W.3d 432, 438 (Te x.

2011)

. Our pr imary o bjective is to give ef fe ct t o the intent of the iss uing agency

, “ w hich

, whe n

pos s ible

, we disc ern from th e plain meaning of the w ords chosen. ” See Heri tage on the San

Ga b riel H

omeowners Ass ’ n v . Texas Comm ’ n o n Env ’ t Quality , 39 3 S .W.3d 417, 425 (Tex.

App.

— A us ti n 20 12, pet

. denied ) (quoting Sta te v. Shumak e

, 199 S.W.3d 279

, 2 8 4 (Te x. 200 6 ) ).

If the rul e is amb iguous , we normally defer to t he age ncy ’ s interpretation unless it is plainly

erroneous or in co ns is te nt with the lang uage of the sta tute, regu la tion, or rule. ” TG S

- NOP EC

Geo p hys ical , 340 S.W.3d at 438

.

MANDAMUS S TA NDAR D

In t his c as e, the parties f ile d comp eting motions for summary judgment on t he

Hosp ital s ’ cl ai ms for ma ndamus relief. A wri t of m an damus may b e us ed t o compel a pub lic9

o fficial to per f

orm a “ mi nister ial act, ” whi ch , for pur pose s o f mandamus

, i s an act w here “ t he law

clearly spells o ut the du ty to be performed by the official with s uffici ent ce r ta in ty that n othing

is left to th e exe rc is e of discre tio n. ” City of Housto n v

. Ho uston Mun. E m p s. P e nsi on Sys

.,

5 49 S.W.3 d 566, 576 ( Tex . 20 18) ; Janek v

. H ar lin ge n Fam

. Dent i stry

, P.C. , 451 S .W .3d 97 , 101

(Tex. App.

— A ustin 2014, no pet. ) ( quotin g Anders on v

. City of Seve n Points

, 806 S.W .2d 7 91

,

793 (Tex. 1991) )

. “ I f an acti on in vo lves personal d eli b er a ti o n, de cisi on, and j udgment, it is

dis cretionary; ac tio ns t hat requi re obe d ience to orders or the p erformance of a duty to wh ich the

actor has no choice ar e ministerial. ” Janek , 451 S. W.3d at 1 01 (citing City of Lancas ter v.

Chambers , 883 S.W. 2d 650, 654 (Tex. 1994 ) ).

ANALY S IS

C laim to Compel an Admi ni str a tiv e Hear in g

I n the ir first issue on app eal

, the Ho sp ital s complain that the trial court erre d in

de nying their motion for summary judgment on the ir claim t o co mpel the O IG to forward their

request for a fo r m a l adminis tra tive hearing to HHSC ’ s Appeal s D i vi sio n for doc keti ng.

S ubchap ter G of Chap ter 37 1 is titled “Administra ti ve A ctions and Sanctio n s, ” and

Rule 371.1615 , found in Subchapter G

, provides t ha t “ [a] person wh o is served w i t h final notice

of a s an ct io n may appe al the i mp os iti o n of the sa nction

. ” 1 T ex. Ad m in. Code § 371 .1 615 (a)

(Appeals)

. Wh e n the OIG receives a r equest for an a dmin istrative hearing at t h e A ppeals

D ivis ion under R ule 371 .1615

, “ the OI G con tacts th e Appeals Divisions

. . . to re q u es t that th e

he a ring be d ocketed. ” Id. § 371 .16 1 5( b) (8)

. I n their mot i on for summary judg me nt

, and now o n

appeal, th e Hospi tals ass ert that th e Utilization R eview Unit ’ s d eci sion to direct the r eco up ment

of funds p rev i ous ly paid to the H os pitals con s ti tu t e s a “ sanc tio n ” under R ule 371.1615 and t hat,10

th er efore, HH SC ha d a min isterial dut y to provide th e Hosp i tals with a formal administrati ve

hea ring

, up on their timely reques t.

In response, HHS C and the OIG asse rt that the t rial court d id n o t er r in c on cluding

th a t the Utilizati on R evi e w Unit ’ s decision d id not tr igg e r a ny ministeri al d ut y on t he part of t he

HHSC to provide a for mal administrat ive hearing bec ause, in HHS C and the OIG ’ s vi ew, a

r ecoupment direc ted as a resul t of Utilization Re v iew is no t a “ s a nctio n ” as that t erm is used

in Rule 3 71.161 5. Upon rev i ew of the relev ant provisions set forth in Cha pter 371 of the T e xas

Administrative Code, w e agree.

Rule 371.1 sets out nin ety

- six de finitio ns app licable to Chap ter 371

. See id

.

§ 371 .1 (Definitio ns) ( “ The following wo rds and terms, wh en used i n t h is cha pter, h av e th e

following meanings unless t he contest clear ly indicates other wise[. ] ” ). Amo ng t he se de finitions

,

t he term “ [ o] verpayme nt ” is def ined , in re lev ant p art, as

[t]he amount paid by Medi cai d o r other HHS pr og ram or the amount c ollect ed or

re ce iv e d by a per s on by virtue of the p rovider ’ s participa tion i n Medicaid or othe r

H HS program that excee ds the amount to which t he provider o r pers on is enti tled

un der [ g ov er n ing Me d icaid law ]. This i ncl udes :

(A) any fu nds c oll ected or rece i ved i n exce ss of the amou n t t o w h ich the pr o vide r

in entitled, whether obta in ed through error

, misunderst and ing , abuse,

misa pplicatio n

, mis use, em bez zlement, imp roper retention, or f r aud [

. ]

Id

. § 371.1(55). In turn

, Rule 371.1(7 2 ) define s the term “ recou pme nt of ov erpayment ” a s “ [ a]

sanction imp osed to recover funds paid to a p rovi der or perso n to which the person was not

e ntitled

. ” Id. § 3 71.1 ( 72 ) ( e mp hasis adde d)

. Final l y

, Rule 3 71.1( 75) defines the t erm “ sanction ”

as “ [a] ny admin ist rative enforcemen t measur e im pos ed b y t h e O IG pur suant to t his su bcha pter

other tha n a dm inistrative acti on s d efined in § 371.1701 o f this subcha pter (relat ing t o11

Administrative Actions). ” S e e i d. § 37 1.1(7 5)

. Althou gh Rule 371.1 701 do es pr o vide a specifi c

d efinition for the phr ase “ admi nis t r at ive action s

, ” th e rul e does include a non

- e xh austi ve list

of tw elve actions that when ta k en by the OI G

, q ualify as “ administrative act ion s. ” See id.

§ 371. 17 01 ( Admini strative Action )

. Th at list consists primarily of non

- monetary a ct i ons a nd

d oes no t e x pressly include recoupment of overpayment arisin g from the T MRP. See id

.

§ 371.1701 (c ) (1 )

- (1 2 ) ; see also id . § 3 71 .1701(d) (providi ng specific not i ce r eq uir em ents for

administ rative act i ons). Based on th e definition s set forth in Ru le 371.1, we co nclu de that a

dec ision by the U t il izati on Review Unit to direct the recoup ment of fun ds from a provider m ay,

at least in some contexts , constitute a “ s a nc ti on. ” N eve rthe less, for t he reason s discussed below,

we cannot c oncl ude that the Util ization R evi ew Un i t ’ s dec ision i n thi s c ase is a “ sancti on ” t hat

entitles the Hospi tals to a dministrative he aring under Rule 371. 1 615

.

As pr eviously discussed, Rule 371 .1 615 provi d e s a right to a n admi nistrative

appeal for th e im p osition of a “sanc tion

. ” S ee id. § 3 71. 1 615

. Howev er, Rule 37 1.1601 states

tha t

, “ [u] nle ss otherw is e pro vided, this subcha pter appli es to al l a dmi nistr a tive ac tions and

sanctions i mpose d by th e OIG and aris i ng out of a n in v est igation of fraud, waste, or abus e. ”

Id. § 3 71.16 01 ( Ap plica b ili t y )

. In o t her words

, the provisions of Su b cha p ter G

, which includ es

Rule 371.1 615

, a re limited to s anctions “ i mposed by the OI G and arising ou t of an in ve stigation

of fraud

, w a st e, or abu se

. ” I d

. ( e mpha sis added)

. Therefore

, an y right t o an admi n ist rativ e appea l

fr om a HHSC or OIG de ci sion to recoup an o verpa yment is lim ited t o those re coupment

decisions “ aris ing out of an investigation of fra ud

, w ast e, o r abu se

. ” Id. ( e mphasis a dded) ; see

Tex. G ov ’ t Code § § 53 1.120 ( “ Not ice and I n formatio n R esol u t i on of Pr opos ed Rec o upment of

Overpaym ent or D eb t, ” providing that HHSC or OIG shall provi de written notice of pro posed

recoupment of overpayment or debt “ ari s i ng out of a fraud o r abuse investigat ion ” )

.12 The pr oc edures fo r condu c t ing an “ investi g atio n ” are det ail ed in Su bc hapt er F of

Chapter 371

. Se e 1 Tex. Admin. Code §§ 371.1301

- .1312 ( Inve stigations )

. For example, after

rec eiving a comp laint, the O IG begins the inves ti gation pr oc ess by conduc ting a “ prelim inary

invest ig ation

, ” as detail ed in Rule 371. 1305

, a n d then “ prep ares a p r eliminary r eport before th e

a lle gation of f

raud or abuse proceeds to a f ul l investigat ion. ” Id. § 371. 1305 (Preliminary

Investiga tio n)

. Th e OIG begin s a full investigation within 30 days of co mple ti n g the prelim inar y

inv est igation if it de termine s that a full in v estigati on i s wa rr a nted. Id. § 371. 13 07 (Full

Investigation)

. T he ful l invest igation must be completed within 1 80 day s un le ss th e OIG

determ ine s t hat more time is needed t o complete t he in v esti gati on. I d. § 37 1 .1307 (c)

. The

resu lts of an investigation may subject a pro v id er to a wide range o f enforcement measures

,

see id. §§ 371.1701

- .1 719, including exclusion from the Med ic aid p ro g ram

, s ee id. § 371. 170 7

( Permis sive Ex clusion )

. Notably

, if the OIG determ ines that an ov erpayment resulted without

w rongdoing, the OIG may re f er the m atter for routine payment c orrect ion by the agency ’ s fi sc al

agent or an operating agency or ma y offer a payment p lan. See id

. § 371.1603(b) (Legal Basis

and Scop e) ; see also id. § 371.1(84) (de fin ing “ s ystem recoupment ” as “ [a]ny action to recov er

funds pa id t o a prov ide r or oth er person to which they wer e not entitled by means other than the

i mpo si tion of sanction under these rules ” and “ may include any routine p ayment correction by an

agency o r an agen cy ’ s fiscal agent to correct an overpaym ent th at re sult ed witho ut wrong doi ng ” ).

B ecaus e the H os p ita ls do not con tend , and the e vidence does no t othe r wi se

sugge st, t hat th e recou pment dec ision at issue in this case arose out of “ an in ves tigatio n of fr aud,

wa ste, or abuse

, ” see id . § 371.1601 ( e mphasis ad d ed)

, we c onc lud e that

, as a matt er of law, the

Ho s p itals were n ot entitled to a n administr ati v e hea r in g under Rule 371.1 615

. Because HHSC

and the OIG did not have a ministerial dut y to provid e th e H ospi ta ls with a formal administrat ive13

hearin g, the tri al cour t di d not err in gran ting summary judgm ent in f avor of HHSC and OIG

on this cla im

.

Cl ai m to Co mpel the Re o

p ening of Tec hnical Denials

N ext, we turn t o the p arties ’ competing appel late iss ue s ch allen ging that portion

of the trial court ’ s order “ co mpell in g [ H HSC and the OIG ] to reopen a ll claims whe re te chnical

de nial of claim s wer e not i ss ued

. ” F irst, we con s ider HHSC a nd the OIG ’ s issue on c ro ss

- appeal,

in w hich they comp lai n th at the trial court erred in grant ing summary j udgment in favo r of the

H ospi ta ls o n t h eir claim t o com pel HHSC to compl y w it h “ proper pro cedures when re viewin g

[me di c al ] re c ords for ad mission den i als. ”

In thei r pleadin gs in the tr ial court , the Hospi tals alleged that HHSC and the OIG

failed to follow pr oper pr ocedures when th ey d en ied so me o f the H ospita ls ’ claim s on th e gro und

tha t t he Ho spitals had p r ovided an in c om plete medical re cord

. S peci fically

, th e Hospit als a rgued

that HHSC and the OIG f aile d to comply with Rule 371. 206(a ) ( 2) , which outlines the ty p e s of

denial that HHS C m ay is sue under TM R P and o th er simila r programs

. See id. § 371. 206(a) ( 1)

-

( 5)

. I n r el e vant part, Rule 371 .206(a )(2 ) authorizes HHSC to deny an admission as a “ tech nical

deni al w hen a hospita l undergo ing TM RP fails to m ak e the com plete medi cal r e c ord availabl e

f or revi ew withi n a spe cifi ed time frame

. ” Id. § 371.206 (a) (2 )

. For mai l

- i n review, the type of

review which occ urred in th is ca se, th is process be gi n s when HHSC reque sts , in writing, that the

hospit al s ubm it copies of medi cal rec ords for u t ilization r evi ew

. Id. § 371. 206( a)( 2) (B). If

the hospital fails to sub mit the comple te me di cal record as requested

, HHSC then issues a

“ prelimi nary technica l deni al ” b y certifie d mail or fax. Id. Upon n otice

, the hos pital t hen ha s 60

calendar days to

, in effect, cu r e th e “ pr elimi nary technica l denial ” by subm it t ing the compl ete

medical r e co rd. Id. If the hospital fails to su bmit the complete medical re cord with in t his time14

f ram e, HH SC then is su es a “ fi nal tec hnic al deni al. ” Id. Based on t he pla in language of Rule

371. 206 (a )(2)(B)

, befo re it m ay deny a claim u nder TMRP review bas ed on an in complete

me dical record

, HHSC must firs t notify the h ospital that it is i ssu ing a prelimi nary technical

de nial bas ed on an incomplete medic al record and that t he hosp ital may supplemen t the medic al

r e co rd within the speci fied time fra me.

In t h e ir motion for summar y judgment

, the Hospitals argue d t hat

, as to at le as t

some of the cla ims denie d by th e Utilizati on R e vie w Uni t and upheld by the M edical Appeals

Uni t

, the undisp u ted evi dence estab lishe s that H HSC and the OIG failed to c omply with the ir

m i n is terial d uty un der Rule 371. 206(a)(2)(B) to provide the Hosp i tal s with an op portunity to

p rov ide additional med ical re c or ds before issuing a fina l de nial of the claim

. In supp or t of t heir

m ot i on f or s um mary ju dgme nt , the Hospital s attached c o p ie s of written not ificat ion s recei ved by

the Hosp itals f

rom the Medical Appeals Unit

, in which the Medica l Appeals Unit exp la in ed t hat

it was u p holding the U tilization R evi ew Un it ’ s denia l as to t hree in

- pa t ie nt admissions because

th e “ docume ntation is i n c om plete and ins ufficie nt

. ” However, a s the H ospitals point out, n o thing

in the re cord

— i ncluding in the “ Notice of Admissio n (s) Den ial ” i nform ing t h e Hospita ls of th e

TMRP and the Utili z ation R ev iew Unit ’ s de cision to deny the cla im s and rec oup payments

—

s ug gests t hat the Hospital s were ever inf o rmed that the Utilization R eview Unit c ons idered the

subm itted me dical record to be in compl ete a s to any admissi o n

, t hat th e Unit was issu ing a

“ prelimina ry te chni cal deni al

, ” or that the Hospitals ha d 60 da ys to s ub m it additional medical

r ecords. S e e id. § 37 1 .2 06 (a) (2)(B). In other words, in the Ho sp it a ls ’ view, the re cord

establishe s that HHSC issu e d technica l denials as to e ach of the se admission s witho u t fi r st

pro vi ding t h e H os p itals with an opport unity t o cur e th e i ncomplete medical rec ord.15 On cr o ss

- appeal

, HHSC and the OIG a ssert that the trial co u rt erred in gran ting

summ ary ju d g ment in f

avor of the Hospitals on the ir cl ai m for mand am us relief relat ing t o

tec hnical d enia ls under Rule 371.2 06 (a) ( 2 ). HHSC and t he OIG d o not dispu t e that the Hospitals

w e re n ever pr ovided with a preliminary technical denial o r any ot her opportunit y to cure th e

“ incomplete an d insufficient ” medical r ecor d . I n stead, t h e y ar gue that onl y t he OIG ’ s U tili zation

R evie w Unit can issue a t echnical denial , and because the evidence establishes that the Medical

Appeals Unit

, an d not the Utiliza tion Re vie w Uni t

, issued t h e w r it ten notification upholding the

d e nial based on “ incom plete and ins uff i ci e nt d o cu ment ation

, ” th e not ifications do no t co nstitute

“ technical denial s ” w ithin the meaning of Rule 371.206(a)(2)(B)

. C on s equently

, HHSC and the

OI G reason

, the r e q uirement of a pre liminary technical denial does not appl y under the fact s of

thi s c a se

. Based on t he plain langu a ge of Rule 3 7 1 .2 06(a)( 2), however, we disagr ee wit h HHSC

and the OIG ’ s contentio n that onl y the Utilizatio n Re vie w Unit can i ssue a techni ca l denial.

While the OIG ’ s Utilization Review Unit has be e n tasked by HHS C wi th t h e

responsi b i li t y of carr ying out utilizat ion r ev iew and the Medical Appeals Unit h as been ta sked

w i th reviewing the Utilization R eview Unit ’ s d e c isions

, Rule 371.2 06 (a )(2)

, b y its e x pre ss terms

,

a ppl ies broadly to den ials issued by “ HH SC

. ” I d

. § 3 71.206(a)( 2) ( “ H HSC issues a technical

d en ial whe n a hospital f

ails to make the compl ete record available for review ” ) ; se e id. § 371.1 (34 )

(de fini ng “ HHSC

, ” to mean “ the Texas Hea lt h and Human Services Commi s si o n, its successo r,

or de sign ee ” ) ; cf.

, e.g.

, id. § § 371.203 (d) ( s pecifically requiring th a t “ t he O I G ” conducts t raining

for prov iders)

, .2 08 ( specifically referr ing to a p p eals of decisions by “ HHS C Utili za tion R e view

Unit ” )

. T here i s no dispute that both t he O IG ’ s Utiliz ation Revie w Un it and the Me d ical

Appeals Unit s a re both divi sions of HHS C. T here f or e, contrary to HHSC and the OIG ’ s

assertion

, the requi rements of Rule 37 1.20 6(a)( 2) are not limi ted to T M RP decision s made by the16

Ut i lizat io n Review Uni t

, an d t he rule d oes not car ve out an y ex cep t ion for denials by t he Medical

A pp eals Uni t

. 5 Conseq u en tly, a deci sion by th e Medical Appeals Unit to uphold a denial based

on its c oncl usion tha t there is “ incom p lete and insuffic ient docum e ntation ” is

, in eff ect, a

“ technical denial ” by HH SC within the meaning of Rule 3 71.206 (a) ( 2( B )

. Base d o n th e

sum m ar y

- judgmen t re cord , we conclu de tha t HHSC failed to comply wi t h it s m inisteria l duty

under Rul e 371.206(a)(2)(B ) to pr ovid e the Hospi t als w ith an oppo r tuni ty to su bmit a comp lete

me dic al record b ef

o re den ying the Hospi tals ’ claims on this g ro und.

Sc o pe and Fo rm o

f Mandamus R elie

f as to Technical Deni als

Having con cluded that the trial court did no t er r in grant ing sum m ar y judg ment on

the H ospitals ’ claim as t o HHSC and the OIG ’ s fai lure to com ply with Rule 371.206 (a ) ( 2 )(B) ’ s

requ iremen ts for i ss ui ng techni c a l den ia ls with r egar d to at least some of the Hospital s ’ c laims

,

we ne xt consider the par ties ’ complaints as to t he f orm o f the m andamu s relief grante d on

this is sue.

In their second appellate iss u e, the Hospi tal s com plain that

, although t he trial

co u r t pr o perly grant ed s u mmary judg ment in th ei r favor on this issue

, the c ourt failed to iss ue the

p recise ma ndamus reli ef re quested a nd to include the d etails ne ces sary for HHSC to comply

.

Spec if ica ll y

, according to t he H o spitals, the y req ue st e d that t ria l c ourt compel HHSC and the

5 In support of thei r a rgument th at the req u ire ments of Rule 371. 206(a)( 2 ) only a ppl y to

de cisi on s to deny made th e Uti lization R eview Un it

, HHSC and th e OIG re ly prima rily on

the proced u res f

or appeals outlined in the 201 0 Texas Medic a i d Prov ider Pro ce d u r e s M a n u a l

( http ://www.tmhp.com )

. To t he extent th e procedures i n the Ma nual re prese n t HHSC ’ s formal

i nt erp retation of Rule 371.206, its ow n administ r ative rule

, we conclude that this inte rpretation

conflicts with the p lain langu age of t h e rule and that, as a result, the la nguage of t he rul e itself

controls. See TG S

- NOP EC Geop hys ica l Co. v. Combs , 340 S. W

. 3d 432, 438 (Tex . 2 011)

(explaining that we do not de fer to agency ’ s interpretation if it “ fails to follow clear,

unam biguous language of its own regulations ” )

.17

OIG to “ comply with the technical denial process set fort h in [ Rule 371.206(a)(2 )(B)] ” an d to

“ reopen al l matte r s where [ HHSC and the OI G ] rec oup e d payment s from [th e H o spita ls] wi thou t

fir st is suing a tec hnic al den ia l and wit h o u t permi tting [ the Ho spitals] t o supplement the medical

records withi n t he tim e per iod spec ified by law. ” I n contrast, the trial co ur t ’ s or der states simply

that t he OIG mu st “ reope n all clai ms w here technical denia l of claims were not i ssue d

. ” The

Ho s pi tals request t hat we modify t h is portion of the judgment and “ render the writ of m andamus

r elating to te chni ca l denials with suffici en t spec ific it y to effectuate th e trial c ourt ’ s ru ling. ” Se e

E t herid ge v. Opit

z

, 5 8 0 S.W.3d 167 , 18 3 (T ex . App.

— Ty ler 20 1 9, pet. dism ’ d) ( “ We have the

au thority to modify incorre ct judgments when the neces sary info rmation i s av aila bl e to do so. ”

(citing T ex . R. A pp. P. 43.2(b) ) )

.

Similarly, HHSC and t he OIG arg ue t hat the ord er ’ s lang uage is “ v o i d for

vagu eness, lack of d ef

init i v e ne ss or specif

icity, and lac k of support by summary

- judgm ent

evide nce. ” They conten d tha t by requ iri ng the Utilization R eview U nit t o “ reopen all claims

where t echnical denial o f claims w ere not is sued

, ” the t rial court ’ s order ( presumably, in erro r) in

fact requ ire s th e Un it to open claims where the H ospitals had su bmi tted a co mplete me dical

record

. In addition, HHSC and the OIG point out that th e o nly claims identified by the Hospitals

in t heir motion for s um m ary jud g me n t were t he thre e s pe cif ic a dmiss ions that were the subject o f

the Medical Appeals Unit ’ s w ritten n o tification s of “ in suff icient docume ntation. ” Th erefore

,

HHSC and th e OIG assert

, any manda mus relief should be l imi ted to these three d enials.

In ef f ec t, the pa r ties agr e e that t he fo r m o f the mandamus r elief gra nted by the

trial cour t is err oneous

. The H ospital s as se rt that the man da mu s relief granted fails to c omport

with th e relief as requested in thei r motion for su m mary judgment and l a cks details n ecessa ry

f or compl i a n ce ; HH SC and the OIG assert tha t , even i f the summary judgmen t is othe rwise18

proper, the s cope of the relief grante d does not conform to the su m mary

- j udg ment re cord

and is overbroad

. Based on the p lead ings and t h e recor d b efore us, we agree wit h the

par t i e s ’ co n ten tio ns

. Becaus e we m ust grant t he relief t he trial cou rt should have, see Dor sett

,

164 S .W.3d at 661

, we mod if y th e second paragraph o f the ord er by remov ing it and replacing it

with the following :

IT IS THEREFOR E ORDERED , ADJUDGED

, AND DEC R E ED that Pl ain tiff s ’

Mot ion for Su mmar y Jud gment i s gr ant ed in part a nd

, a ccordingly, a s to the

deni als issued by HHS C and re f lected in the Medical Appeal s Unit ’ s thr ee written

notifications ( dated : Jun e 3, 2010 ; February 24, 2010 ; and June 2, 20 1 0 ; and

la b el ed : TP I# : 094113001 ; TPI# 0942179 02 ; and TPI# 0 9411 300 1

, re spe c tiv e ly )

HHSC must w ithdraw it d eni als on these cl ai ms

, reo pen the se claims

, and co mp l y

w ith the proc edures set forth in Rule 371 .206 (B)( 2) by issu ing a preliminary

te chnical den i al by cer t i f ied ma il an d notifyin g the Hosp itals that they have 6 0

ca len dar d a ys fr om the date of the n o t ice to submit the c omple te m edical record

and that if t h ey do not, HHSC w ill issue a final technical denial.

See Te x. R. App. P. 43.2( b ) ( authori z in g courts o f a p peals t o mo dify trial court ’ s jud gmen t an d

af firm as modi fied )

.

CO NCL USION

Having sustained th e Hosp itals ’ seco nd issu e on app ea l

, we modify the judgm ent

, as

described abo ve

, and affi rm th e trial court ’ s summary

- judgme nt order a s mo d i fi ed.

__________ _________________________ _______

Chari L. Kel ly

, Justice

Bef ore Ju stic es G o odwi n

, Kelly, and Smith

Modified and, as M o dified, A ffirmed

Fi led: March 18, 2021