Court Opinion

ID: 6316857
Source: CourtListenerOpinion
Date Created: 2022-02-23 20:01:13.580922+00
Date Added: 2024-06-11T09:00:32.363428
License: Public Domain

Case: 21-20168     Document: 00516213545          Page: 1    Date Filed: 02/23/2022

           United States Court of Appeals
                for the Fifth Circuit                                  United States Court of Appeals
                                                                                Fifth Circuit

                                                                              FILED
                                                                       February 23, 2022
                                   No. 21-20168                          Lyle W. Cayce
                                                                              Clerk

   ACS Primary Care Physicians Southwest, P.A.; Hill
   County Emergency Medical Associates, P.A.; Longhorn
   Emergency Medical Associates, P.A.; Central Texas
   Emergency Associates, P.A.; Emergency Associates of
   Central Texas, P.A.; Emergency Services of Texas, P.A.,

                                                            Plaintiffs—Appellees,

                                       versus

   UnitedHealthcare Insurance Company;
   UnitedHealthcare of Texas, Incorporated,

                                                        Defendants—Appellants.

                  Appeal from the United States District Court
                      for the Southern District of Texas
                           USDC No. 4:20-CV-1282

   Before King, Graves, and Ho, Circuit Judges.
   King, Circuit Judge:
          Texas state law requires that health plan administrators pay
   emergency-care providers their “usual and customary rate” when those
   providers give emergent care to an out-of-network plan enrollee. Today, we
   are asked whether that same state law also creates an implied private right of
Case: 21-20168     Document: 00516213545             Page: 2   Date Filed: 02/23/2022

                                    No. 21-20168

   action on behalf of those emergency-care providers. For the reasons
   discussed below, we CERTIFY to the Supreme Court of Texas.
                                          I.
          The plaintiffs-appellees are emergency-care physician groups
   (“Plaintiff   Doctors”)   in   Texas        and   the   defendants-appellants—
   UnitedHealthcare Insurance Company and UnitedHealthcare of Texas
   (collectively, “UHC”)—are health insurance companies. The Plaintiff
   Doctors did not participate in UHC’s provider network. Nevertheless, by
   law, the Plaintiff Doctors must serve all those who require emergent care
   regardless of whether their patient is in-network. Texas law also imposes a
   minimum payment owed to the Plaintiff Doctors when they provide such
   care: emergency-care providers must be paid their “usual and customary
   rate[s]” for care provided to out-of-network plan enrollees. Tex. Ins.
   Code §§ 1271.155(a) (applicable to Health Maintenance Organizations),
   1301.0053(a) (applicable to Exclusive Provider Organizations), and
   1301.155(b) (applicable to Preferred Provider Organizations). These statutes,
   called the “emergency-care” statutes, read:
          § 1271.155(a): A health maintenance organization shall pay for
          emergency care performed by non-network physicians or
          providers at the usual and customary rate or at an agreed rate.

          § 1301.0053(a): If an out-of-network provider provides
          emergency care as defined by Section 1301.155 to an enrollee in
          an exclusive provider benefit plan, the issuer of the plan shall
          reimburse the out-of-network provider at the usual and
          customary rate or at a rate agreed to by the issuer and the out-
          of-network provider for the provision of the services and any
          supply related to those services.

          § 1301.155(b): If an insured cannot reasonably reach a preferred
          provider, an insurer shall provide reimbursement for the

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           following emergency care services at the usual and customary
           rate or at an agreed rate and at the preferred level of benefits
           until the insured can reasonably be expected to transfer to a
           preferred provider[.]

   The Plaintiff Doctors provided various emergency medical services to
   patients enrolled in UHC’s healthcare plans from January 2016 to the present
   day. All parties agreed that some amount of money must be paid by UHC to
   the Plaintiff Doctors; however, the Plaintiff Doctors believed that they were
   “paid at unacceptably low rates,” well below their “usual and customary
   rates,” and thus brought suit in Texas state court. UHC promptly removed
   the case to the federal district court for the Southern District of Texas.
           The Plaintiff Doctors alleged that UHC violated the emergency-care
   statutes by failing to pay the “usual and customary rate[s].” 1 The district
   court dismissed the plaintiffs’ claims under Texas Insurance Code
   § 1303.155(b) (the statute applicable to PPOs) for claims dated from January
   1, 2016, to December 31, 2019, but it found that the remaining emergency-
   care statute claims survived.
           UHC immediately sought an interlocutory review of two issues:
   (1) whether the emergency-care statutes provide for an implied private right
   of action; and (2) if so, whether ERISA § 514 preempts the claims brought
   under the emergency-care statutes. 2 Both the district court and this circuit
   granted UHC’s request for interlocutory review. Soon after, on April 22,
   2021, the Plaintiff Doctors moved to certify the first issue to the Texas
   Supreme Court.

           1
             Appellees also brought breach of contract and quantum meruit claims, but these
   are not relevant to this appeal.
           2
            Because we certify the first issue to the Texas Supreme Court, we do not address
   the second issue at this time.

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                                         II.
          This court may certify a question to the Supreme Court of Texas. See
   McMillan v. Amazon.com, Inc., 983 F.3d 194, 202 (5th Cir. 2020). We look to
   three factors to determine whether certification is proper:
          (1) the closeness of the question and the existence of sufficient
          sources of state law; (2) the degree to which considerations of
          comity are relevant in light of the particular issue and case to
          be decided; and (3) practical limitations of the certification
          process: significant delay and possible inability to frame the
          issue so as to produce a helpful response on the part of the state
          court.
   Id. (quoting Silguero v. CSL Plasma, Inc., 907 F.3d 323, 332 (5th Cir. 2018)).
   Here, each factor advises that we certify.
          The first factor—the closeness of the question and the existence of
   sufficient sources of state law—favors certification. The question of whether
   the emergency-care statutes create an implied private right of action is a close
   one, and both parties present strong arguments in their favor. Under Texas
   law, an implied right of action may be found only if the plain language of the
   statutory text supports one. Brown v. De La Cruz, 156 S.W.3d 560, 563 (Tex.
   2004). The plaintiffs point us to Texas Supreme Court precedents that found
   implied rights of action in similarly precise statutory and constitutional
   language. See City of Beaumont v. Bouillion, 896 S.W.2d 143, 149 (Tex. 1995)
   (finding an implied right of action in “no person’s property shall be taken,
   damaged or destroyed for or applied to public use without adequate
   compensation”). But see Brown, 156 S.W.3d at 561-62 (finding an implied
   right of action in “[seller] is liable to the purchaser for . . . liquidated
   damages” but no implied right of action in “[seller is] ‘subject to a penalty’
   of up to $500 a day.”). Here, the emergency-care statutes provide what must

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   be paid (the “usual and customary rate”), who shall pay it (“an issuer of a
   plan”), and who shall be paid (an “out-of-network provider”). Therefore, a
   court could plausibly read the emergency-care statutes to provide an implied
   right of action, as the district court did.
           On the other hand, these same Texas Supreme Court precedents
   adopt a rule of “strict construction” for courts reviewing a statute for an
   implied right of action. Brown, 156 S.W.3d at 566-67. Applying that rule, a
   Texas state appellate court has found that the emergency-care statutes do not
   provide an implied private right of action. Tex. Med. Res., LLP v. Molina
   Healthcare of Tex., Inc., 620 S.W.3d 458 (Tex. App.—Dallas 2021, pet.
   filed). 3 It explained that, given the detailed regulatory code from which the
   emergency-care statutes arise and the fact that the Texas Insurance Code
   expressly creates causes of action in other sections, it would be inappropriate
   to imply one here. Id. at 464-65. That, too, is a plausible reading. Thus, “any
   Erie guess would involve more divining than discerning,” and certification is
   the favored route. McMillan, 983 F.3d at 202.
           The second factor—comity—also strongly favors certification. In
   McMillan, we explained that “federal-to-state certification is prudent when
   consequential state-law ground is to be plowed, such as defining and
   delimiting state causes of action.” Id. And that is precisely what the parties
   are asking this court to do. Whether there is an implied private right of action
   within the emergency-care statutes either enables or eliminates thousands of
   claims regarding the underpayment of insurers to non-network healthcare
   providers. Certainly, the state of Texas has a strong interest in the answer.

           3
              The Texas Supreme Court has since requested full merits briefing on the issue.
   Brief on the Merits Requested, Tex. Med. Res., LLP v. Molina Healthcare of Tex., Inc., No. 21-
   0291 (Tex. Sept. 24, 2021).

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          The third factor—practical limitations on the certification process—
   favors certification as well. The question posed is a legal one that is simple to
   frame (even if difficult to answer). The risk of delay is also minimal; “[t]o its
   immense credit, and for several years in a row, the Supreme Court of Texas
   has decided every argued case by the end of June.” Id. at 203, certified question
   accepted (Jan. 8, 2021), certified question answered, 625 S.W.3d 101 (Tex.
   2021). We are confident that, should the Court accept the certified question,
   its streak of timely decisions will continue.
                                         III.
          We certify the following question of state law to the Supreme Court
   of Texas:
          Do §§ 1271.155(a), 1301.0053(a), and 1301.155(b) of the Texas
          Insurance Code authorize Plaintiff Doctors to bring a private
          cause of action against UHC for UHC’s failure to reimburse
          Plaintiff Doctors for out-of-network emergency care at a
          “usual and customary” rate?
   We disclaim any intention or desire that the Court confine its reply to the
   precise form or scope of the question certified.
          QUESTION CERTIFIED.

                                                   A True Copy
                                                   Certified Feb 23, 2022

                                                   Clerk, U.S. Court of Appeals, Fifth Circuit

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