Court Opinion

ID: 4696740
Source: CourtListenerOpinion
Date Created: 2021-06-18 00:00:34.966516+00
Date Added: 2024-06-11T08:05:42.209251
License: Public Domain

Case: 20-20032      Document: 00515904031        Page: 1    Date Filed: 06/17/2021

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

                                                                           FILED
                                                                       June 17, 2021
                                  No. 20-20032
                                                                      Lyle W. Cayce
                                                                           Clerk
   IMA, Incorporated,

                                                            Plaintiff—Appellee,

                                      versus

   Columbia Hospital Medical City at Dallas, Subsidiary
   L.P., doing business as Medical City Dallas Hospital,

                                                         Defendant—Appellant.

                   Appeal from the United States District Court
                       for the Southern District of Texas
                            USDC No. 4:19-CV-3500

   Before Higginbotham, Jones, and Higginson, Circuit Judges.
   Stephen A. Higginson, Circuit Judge:
         Columbia Hospital Medical Center at Dallas, L.P., d/b/a Medical
   City Dallas Hospital (“Columbia Hospital”) seeks to compel IMA, Inc., a
   health plan administrator, to arbitrate a dispute involving unreimbursed
   medical fees.    The parties are connected by a series of intermediary
   agreements within a preferred provider organization (“PPO”) network that
   allows patients in covered health plans to receive medical services from
   participating hospitals at discounted rates. One of those agreements contains
   an arbitration clause. The district court denied Columbia Hospital’s motion
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   to compel arbitration, holding that IMA is not a party to, and is not otherwise
   bound by, the agreement containing the arbitration provision. On appeal,
   Columbia Hospital argues that the district court erred in declining to compel
   arbitration under direct benefits estoppel, or alternatively to construe the
   series of agreements as a single, unified contract. We AFFIRM.
                                         I.
          IMA is the third-party administrator of the Central Management
   Company, LLC Employer Health Plan (“Health Plan”), which IMA
   maintains is covered by ERISA. In February 2016, T.S., a member of the
   Health Plan, received two spinal surgeries at Columbia Hospital. Prior to the
   surgeries, Columbia Hospital obtained authorization numbers confirming
   that T.S. was a member of an in-network health plan. Columbia Hospital
   subsequently sought reimbursement for the surgeries and spine implants
   from IMA.
          It is undisputed that IMA, a plan administrator, and Columbia
   Hospital, a services provider, do not have a direct contract with one another.
   Instead, they are connected through a series of intermediary agreements
   entered into over approximately ten years that connect hospitals (like
   Columbia Hospital) with various PPO networks, then to plan administrators
   (like IMA), and finally to health plans and patients.
          A.     Relevant agreements
          Effective April 2012, Columbia Hospital agreed to provide discounted
   services to HealthSmart Preferred Care II, L.L.C. (“HealthSmart”), a PPO
   network. The terms of this arrangement were entered in a “Hospital
   Agreement” between Hospital Corporation of America North Texas
   Division, Inc. (“HCA”), acting on behalf of Columbia Hospital and other
   hospitals, and HealthSmart. Pursuant to this agreement, Columbia Hospital
   would provide services as a “Participating Hospital” to the HealthSmart

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   network and its “Groups,”1 based on the discounted reimbursement rates
   specified in “Exhibit B,” which was attached to the agreement. In turn,
   HealthSmart agreed to “ensure that any Group accessing [Columbia
   Hospital’s] rates . . . is contractually bound to [Columbia Hospital] to adhere
   to the terms and conditions of this Agreement,” and that HealthSmart “shall
   require” the Group to pay the rates specified in Exhibit B. The Hospital
   Agreement also contains the following arbitration provision:
           Dispute Resolution. Any dispute arising out of, relating to,
           involving the interpretation of, or in any other way pertaining
           to this Agreement shall be resolved using alternative dispute
           resolution mechanisms instead of litigation. Network, Group,
           and Participating Hospital agree and acknowledge that it is
           their mutual intention that this provision be construed broadly
           so as to provide for mediation and/or arbitration of all disputes
           arising out of this relationship.
           IMA, as a plan administrator, similarly entered into agreements with
   PPO networks so that its members could access discounted medical services
   with “hundreds of providers.” One of those agreements was a Preferred
   Provider Organization TPA Agreement with PPOplus, LLC, effective March
   2003, so almost a decade earlier (the “IMA-PPOplus Agreement”). This

           1
             “Group” is defined as “any entity” including “an association, employer, federal
   or state reimbursement program, . . . preferred provider organization, . . . third party
   administrator, [or] healthcare service plan . . . that is approved by [Columbia Hospital] and
   that provides a Plan and that pays or agrees to pay [Columbia Hospital] for the Covered
   Services it provides to Covered Person(s) pursuant to terms and conditions of this
   Agreement.”
          “Plan” is defined as a “health benefits plan for which a Group has entered into a
   Group Agreement with [HealthSmart] to arrange for the provision of Covered Services to
   Covered Person(s).”

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   contract allows IMA to access the “Participating Providers”2 in the PPOplus
   network at the “PPO Contracted Rates,” which are defined as the “rates or
   fees agreed upon by PPO and Participating Provider.” Relevant here, IMA
   “agrees to pay claims of Participating Providers in accordance with the
   applicable Plan and the PPO Contracted Rates,” and to pay PPOplus a
   “Network Access Fee.” In exchange, PPOplus is required to “directly or
   indirectly arrange for, enter into, maintain, and enforce Provider Agreements
   with . . . Participating Providers.” This 2003 contract with IMA as a
   signatory does not include an arbitration clause.
           A year earlier in 2002, PPOplus entered into a “Network Cross
   Access Agreement” with HealthSmart.3                     This agreement provides
   “reciprocal access” between PPOplus and HealthCare’s network of
   providers. In return, both networks “shall require their respective Clients to
   pay the claims of the other party’s Participating Providers in accordance with
   the applicable Plan and the other party’s Contracted Rates.” This agreement
   similarly does not have an arbitration clause.
           In sum, Columbia Hospital contracted with HealthSmart, which
   separately contracted with PPOplus, which had contracted almost a decade
   earlier with IMA, which administered T.S.’s health plan. Only the 2012
   Hospital Agreement between Columbia Hospital and HealthSmart contains
   an arbitration provision.

           2
             “Participating Provider” is defined as a “provider or group of providers
   (including any hospital, physician, or other health care provider) who has entered into a
   contractual agreement with PPO to provide Covered Services to Beneficiaries.”
           3
            While the party to this agreement, HealthSmart Preferred Care, Inc., is different
   from the party to the Hospital Agreement, HealthSmart Preferred Care II, L.L.C., neither
   party disputes that the two entities are related or that IMA accessed HealthSmart’s
   network, including Columbia Hospital, through the Network Cross Access Agreement.

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          B.     Claim reimbursement dispute
          This dispute arises from Columbia Hospital’s attempt to collect over
   $2.7 million for T.S.’s surgeries, including inpatient care and implants in his
   back and spine. Columbia Hospital’s “billed charges” were $1,165,116.80
   for the first surgery and $1,548,885.57 for the second surgery, totaling
   $2,714.002.37. IMA at first declined to pay and requested further records to
   explain the cost of the implants. In October 2016, HCA’s senior counsel sent
   a letter on behalf of Columbia Hospital to HealthSmart related to these
   unreimbursed claims “pursuant to [Columbia Hospital’s] agreement with
   HealthSmart.”      This letter further sought “HealthSmart’s position
   regarding [IMA’s] refusal to process or pay claims until and unless the facility
   provides cost invoicing for implants,” and stated that “[a]ction must be
   taken to address the existing gap in understanding between [HealthSmart’s]
   client and the facilities who serve their members.” A copy of this letter was
   sent to IMA’s legal department.
          In March 2018, IMA subsequently paid Columbia Hospital
   $1,014,161.97. This payment did not cover any of the costs of the implants—
   totaling an additional $1,361,786.46—which IMA deemed “ineligible” and
   “exceed[ing] the maximum allowed based on the reasonable and customary
   amount” under its plan. For the services IMA did reimburse, it paid a
   discounted amount of 75% of the billed costs. Specifically, IMA’s explanation
   of benefits indicated that the discount code, “2226,” was pursuant to the
   “PPO Plus/HealthSmart/PHCS/1st Health . . . discount.” This discount
   rate matches the discount stated in Exhibit B of the Hospital Agreement for
   the “stop loss” provision of 75% of billed costs.          Columbia Hospital
   maintains, however, that IMA was required to further reimburse it for the
   implants, at the same 75% discounted rate, totaling an additional
   $1,021,339.85.

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          C.     Procedural history
          In July 2019, Columbia Hospital filed a demand for arbitration against
   IMA in Houston, Texas, alleging breach of contract for the unreimbursed
   amount of T.S.’s surgery implants. In response, IMA initiated this lawsuit
   in the Southern District of Texas seeking declaratory and injunctive relief
   that it is not obligated to arbitrate the dispute because it is not a signatory to
   the Hospital Agreement and that it is not obligated to pay the disputed
   amount.
          Columbia Hospital moved to stay the district court proceedings and
   compel arbitration. It argued that IMA was bound by the 2012 arbitration
   clause in the Hospital Agreement because the series of agreements between
   Columbia Hospital, HealthSmart, PPOplus, and IMA form a “single, unified
   contract.” Alternatively, Columbia Hospital argued that even as a non-
   signatory to the Hospital Agreement, IMA was bound by the arbitration
   clause because it knowingly received the benefits of the discounted services
   provided in the agreement.
          The district court disagreed on both grounds and denied the motion
   to compel arbitration. IMA, Inc. v. Columbia Hosp. Med. City at Dallas,
   Subsidiary, L.P., No. CV H-19-3500, 2019 WL 7168099, at *4 (S.D. Tex.
   Dec. 23, 2019). Columbia Hospital timely appealed.
                                          II.
          A district court’s denial of a motion to compel arbitration is reviewed
   de novo. Bowles v. OneMain Fin. Grp., L.L.C., 954 F.3d 722, 725 (5th Cir.
   2020). We review the district court’s findings of fact for clear error.

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   Crawford Prof’l Drugs, Inc. v. CVS Caremark Corp., 748 F.3d 249, 256 (5th
   Cir. 2014).
          The district court’s application of direct benefits estoppel is reviewed
   for an abuse of discretion. Noble Drilling Servs., Inc. v. Certex USA, Inc., 620
   F.3d 469, 472–73 (5th Cir. 2010). “To constitute an abuse of discretion, the
   district court’s decision must be either premised on an application of the law
   that is erroneous, or on an assessment of the evidence that is clearly
   erroneous.’” Id. at 473 (quoting Grigson v. Creative Artists Agency L.L.C., 210
   F.3d 524, 528 (5th Cir. 2000)).
                                         III.
          Whether IMA is compelled to arbitrate this reimbursement dispute
   turns on the threshold question of “whether the parties entered into any
   arbitration agreement at all.” Kubala v. Supreme Prod. Servs., Inc., 830 F.3d
   199, 201 (5th Cir. 2016) (emphasis omitted); see also Will-Drill Res., Inc. v.
   Samson Res. Co., 352 F.3d 211, 218 (5th Cir. 2003) (“[B]ecause arbitration is
   a matter of contract, where a party contends that it has not signed any
   agreement to arbitrate, the court must first determine if there is an agreement
   to arbitrate before any additional dispute can be sent to arbitration.”). If no
   arbitration contract between IMA and Columbia Hospital was formed, we
   need not consider whether the scope of the arbitration agreement includes
   the disputed reimbursement claim. Cf. Tittle v. Enron Corp., 463 F.3d 410,
   419 (5th Cir. 2006) (determining scope of arbitration clause only because
   there was no dispute that the parties were subject to a valid arbitration
   agreement).
          We apply “ordinary state-law principles that govern the formation of
   contracts” to determine whether an arbitration contract was formed. First
   Options of Chicago, Inc. v. Kaplan, 514 U.S. 938, 944 (1995). Likewise,
   whether a party can compel a non-signatory to arbitrate on equitable grounds

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   is determined by state law. Crawford Pro. Drugs, Inc. v. CVS Caremark Corp.,
   748 F.3d 249, 261 (5th Cir. 2014) (citing Arthur Andersen LLP v. Carlisle, 556
   U.S. 624 (2009)). The parties do not dispute that Texas law applies here.
   The “federal policy favoring arbitration does not apply to the determination
   of whether there is a valid agreement to arbitrate between the parties.”
   Fleetwood Enters., Inc. v. Gaskamp, 280 F.3d 1069, 1073 (5th Cir.), opinion
   supplemented on denial of reh’g, 303 F.3d 570 (5th Cir. 2002).
          “In order to be subject to arbitral jurisdiction, a party must generally
   be a signatory to a contract containing an arbitration clause.”              Bridas
   S.A.P.I.C. v. Gov’t of Turkmenistan, 345 F.3d 347, 353 (5th Cir. 2003).
   “Arbitration    agreements    apply    to   nonsignatories       only   in     rare
   circumstances.” Id. at 358. While it is undisputed that IMA is not a party or
   signatory to the Hospital Agreement that contains the arbitration clause,
   Columbia Hospital argues that IMA is nonetheless required to arbitrate
   under direct benefits estoppel, or alternatively under a unified contract
   theory.
          A.      Direct benefits estoppel
          Direct benefits estoppel applies to “non-signatories who, during the
   life of the contract, have embraced the contract despite their non-signatory
   status but then, during litigation, attempt to repudiate the arbitration clause
   in the contract.” Hellenic Inv. Fund, Inc. v. Det Norske Veritas, 464 F.3d 514,
   517–18 (5th Cir. 2006) (internal quotation marks and citation omitted).
   Texas’s application of direct benefits estoppel is consistent with federal law.
   In re Weekley Homes, L.P., 180 S.W.3d 127, 134–35 (Tex. 2005).
          “A non-signatory can ‘embrace’ a contract containing an arbitration
   clause in two ways: (1) by knowingly seeking and obtaining ‘direct benefits’
   from that contract; or (2) by seeking to enforce the terms of that contract or
   asserting claims that must be determined by reference to that contract.”

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   Noble Drilling, 620 F.3d at 473.4 Columbia Hospital asserts only that the first
   ground applies here. Accordingly, “[t]o invoke direct-benefits estoppel
   under this theory . . . [IMA] must have known about the existence of the
   contract and its terms, and acted to exploit that contract. Second, [IMA]
   must have obtained some benefit under the contract.” In re Lloyd’s Reg. N.
   Am., Inc., 780 F.3d 283, 291 (5th Cir. 2015) (citing Noble Drilling, 620 F.3d
   at 473–74).
           The district court declined to apply direct benefits estoppel because it
   determined that, factually, Columbia Hospital “failed to show that IMA had
   knowledge of the existence and terms, including the arbitration provision, of
   the Hospital [Agreement].”             IMA, Inc., 2019 WL 7168099, at *3.                  It
   emphasized that in order to comply with its obligations, IMA needed only “a
   copy of the Plan and the PPO Contracted Rates,” the latter of which were
   contained in “an attachment to the relevant contract, and are not set forth in
   the contracts themselves.” Id. Because the district court concluded that
   IMA was not shown to have the requisite knowledge of the Hospital
   Agreement, it did not reach the second issue of whether IMA obtained
   “direct benefits” from the Hospital Agreement.

           4
             While not dispositive, “the archetypal direct-benefits case” applies where “the
   party opposing arbitration seeks to enforce the terms of an agreement with an arbitration
   clause.” Jody James Farms, JV v. Altman Grp., Inc., 547 S.W.3d 624, 637 (Tex. 2018)
   (citing Rachal v. Reitz, 403 S.W.3d 840, 847 (Tex. 2013)); see also Bridas, 345 F.3d at 362
   (noting “an important distinction . . . between cases where the courts seriously consider
   applying direct benefits estoppel” is whether the “nonsignatory had brought suit against a
   signatory premised in part upon the agreement.”); Scott M. McElhaney, Enforcing and
   Avoiding Arbitration Clauses Under Texas Law, 37 Corp. Couns. Rev. 109, 139 (2018) (“In
   situation[s] in which signatories seek to compel arbitration of the claims they assert against
   non-signatories . . . principles of estoppel have not been as successful.”).

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                                         1.
          Columbia Hospital first argues that the district court legally erred, and
   thereby abused its discretion, by requiring that IMA have specific knowledge
   of the arbitration provision for direct benefits estoppel to apply, when it is
   sufficient that a “non-signatory have had actual knowledge of the contract
   containing the arbitration clause.” Noble Drilling, 620 F.3d at 473 (emphasis
   added). Not so. The district court correctly applied our circuit’s precedent
   that knowledge of the agreement requires knowledge of the contract’s “basic
   terms.” See In re Lloyd’s Reg., 780 F.3d at 292.
          Columbia Hospital relies on Vloeibare Pret Ltd. v. Lloyd’s Register
   North America, Inc., in which we applied direct benefits estoppel over the
   non-signatory party’s objection that it was “unaware” of a specific forum
   selection clause within a contract. 606 F. App’x 782, 785 (5th Cir. 2015) (per
   curiam) (unpublished). In that case, we held that it was sufficient that the
   non-signatory was “aware both of the existence of the . . . contract and its
   basic terms” because its complaint referenced the contract and “outlined
   extensively the obligations that [the signatory defendant] had under the
   contract.” Id. Vloeibare is consistent with the district court’s application of
   direct benefits estoppel here, as the district court concluded that IMA lacked
   knowledge of the “existence and terms, including the arbitration provision,
   of the Hospital [Agreement].” IMA, Inc., 2019 WL 7168099, at *3 (emphasis
   added).    The district court did not apply a heightened knowledge
   requirement.
                                         2.
          Columbia Hospital next argues that the district court clearly erred
   factually in concluding that IMA lacked knowledge of the basic terms of the

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   Hospital Agreement.5 The crux of the district court’s decision was that IMA
   neither was shown to have, nor needed, knowledge of the Hospital
   Agreement in order to fulfill its obligations to the Health Plan and the IMA-
   PPOplus Agreement; rather IMA could process the claims with “a copy of
   the [Health] Plan and the PPO Contract Rates.” Id. Consequently, the
   district court declined to infer that IMA’s partial reimbursement to
   Columbia Hospital showed knowledge of the underlying Hospital Agreement
   or its terms. Id.
           Columbia Hospital asserts that the district court clearly erred because
   it ignored the record evidence showing that IMA preauthorized T.S.’s
   surgeries and subsequently reimbursed Columbia Hospital, in part, at the
   discounted rates. To constitute an abuse of discretion, the district court’s
   evaluation of the evidence must be “premised . . . on an assessment of the
   evidence that is clearly erroneous.” Noble Drilling, 620 F.3d at 472–73.
           First, Columbia Hospital says that IMA knew about the Hospital
   Agreement when it twice preauthorized T.S.’s surgeries as in-network
   services because such authorization “presupposes the existence of the
   Hospital Agreement.” The record is sparse as to what this preauthorization
   entails or the significance of IMA’s “authorization numbers.” The parties
   agree that IMA’s preauthorization at a minimum confirmed that T.S. was a
   member of the Health Plan and that Columbia Hospital was an in-network,
   preferred services provider. But nothing in the record establishes that this
   preauthorization “presupposes” knowledge of the Hospital Agreement, let

           5
            We reject Columbia Hospital’s contention that the district court legally erred by
   concluding that IMA’s knowledge of the discount terms was insufficient to constitute
   knowledge of the Hospital Agreement and its basic terms. Whether IMA knew of the
   discount terms attached to the Hospital Agreement is a factual determination, which we
   review for clear error. Noble Drilling, 602 F.3d at 472–73.

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   alone its discount terms, beyond a generalized relationship between T.S.’s
   health plan and the PPO network. See Noble Drilling, 620 F.3d at 473; see also
   Pershing, L.L.C. v. Bevis, 606 F. App’x 754, 758 (5th Cir. 2015) (per curiam)
   (unpublished) (“A nonsignatory must have specific knowledge of the
   relevant agreement—a nonsignatory’s generalized sense that two
   contracting parties have a course of dealing will not satisfy this
   requirement.”). Consequently, the district court did not clearly err in
   declining to rely on the authorization numbers as evidence that IMA had
   knowledge of the Hospital Agreement and its basic terms.
          Second, Columbia Hospital asserts that IMA knew the basic terms of
   the Hospital Agreement when, in March 2018, it partially reimbursed
   Columbia Hospital at the agreed-upon discounted rate.               Specifically,
   Columbia      Hospital    argues     that    IMA       even    referenced    the
   “PPOplus/HealthSmart” discount in its payment explanation.
          IMA counters that its network providers—PPOplus, who in turn
   contracted with HealthSmart—reprice the claims. In support, IMA points
   to a declaration from its VP of Operations stating that “IMA does not receive
   a copy of the agreements with the hospitals or other providers” and that
   “IMA does not know the discount amount until after it has been repriced by
   the PPO.”
          Based on this record, the district court did not clearly err in relying on
   IMA’s declaration to conclude that “[t]here is no reason IMA would need to
   know the terms of the Hospital [Agreement], and there is no evidence that it
   knew those terms.” IMA, Inc., 2019 WL 7168099, at *3. Additionally, the
   discount code that Columbia Hospital principally relies on refers to three
   other PPO networks in addition to PPOplus and HealthSmart, which is
   further indicative of the parties’ participation in various network
   arrangements rather than knowledge of one specific agreement.

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           Alternatively, Columbia Hospital argues that IMA knew of the
   Hospital Agreement upon receipt of the October 2016 demand letter, which
   quoted various provisions of the Hospital Agreement including the applicable
   discount rates. Specifically, the letter excerpted two lines from the Hospital
   Agreement’s Exhibit B, including the discounted 75% “stop loss” provision
   that IMA subsequently applied in its partial payment to Columbia Hospital.
   Notably, this letter was addressed to HealthSmart (which similarly did not
   have a direct contract with IMA), sought HealthSmart’s position regarding
   IMA’s “refusal to process or pay claims,” and did not seek a response or
   other action from IMA.
           The district court noted that this letter “fail[ed] to present evidence
   that IMA knew the arbitration terms of the Hospital [Agreement],” IMA, Inc.,
   2019 WL 7168099, at *3 n.4 (emphasis added), but the district court did not
   address whether this letter established that IMA then knew of the Hospital
   Agreement’s existence or its basic terms. See In re Lloyd’s Reg., 780 F.3d at
   292; Vloeibare, 606 F. App’x at 785. Nonetheless, the record does not show
   that the district court clearly erred in concluding that IMA could comply with
   its payment obligations at the discounted rates contained in the Hospital
   Agreement by relying on the PPO networks, including PPOplus and
   Healthsmart, to apply the agreed-upon discounts.
           Consequently, the district court did not clearly err in concluding,
   based on the record before it, that IMA lacked the requisite knowledge of the
   Hospital Agreement and its basic terms to be compelled to arbitrate under
   direct benefits estoppel.6

           6
             Like the district court, we do not reach the second direct benefits estoppel inquiry
   of whether IMA directly benefitted from the contract. See In re Lloyd’s Reg., 780 F.3d at
   292; see also Am. Bureau of Shipping v. Tencara Shipyard S.P.A., 170 F.3d 349, 351, 353 (2d
   Cir. 1999) (concluding, where it was undisputed that all parties had knowledge of the

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           B.      Unified contract
           Alternatively, Columbia Hospital argues that IMA is bound by the
   arbitration clause in the Hospital Agreement because the series of contracts
   between IMA, PPOplus, HealthSmart, and Columbia Hospital—which
   together “created this preferred-provider network”—should be construed
   as a single, unified contract.
           Under Texas law, “instruments pertaining to the same transaction
   may be read together to ascertain the parties’ intent.” Fort Worth Indep. Sch.
   Dist. v. City of Fort Worth, 22 S.W.3d 831, 840 (Tex. 2000). This can apply
   “even if the parties executed the instruments at different times and the
   instruments do not expressly refer to each other.” Id. In such circumstances,
   “courts may construe all the documents as if they were part of a single,
   unified instrument.” Id. However, the Texas Supreme Court has repeatedly
   cautioned that “tethering documents to each other is ‘simply a device for
   ascertaining and giving effect to the intention of the parties and cannot be
   applied arbitrarily and without regard to the realities of the situation.’”
   Rieder v. Woods, 603 S.W.3d 86, 94–95 (Tex. 2020) (quoting Miles v. Martin,
   321 S.W.2d 62, 65 (Tex. 1959)).
           The district court declined to construe the agreements as a single,
   unified contract because they each contained “Entire Agreement”
   provisions.7 On appeal, Columbia Hospital asserts that these provisions do
   not bar construing the contracts together because “the agreements at issue
   repeatedly cross-reference each other.” We review the district court’s legal

   contract containing an arbitration clause, that the non-signatories directly benefitted from
   that contract, and were thus bound to arbitrate).
           7
              An “entire-agreement clause” is also commonly termed an “entire-contract
   clause,” “integration clause,” or “merger clause.” Black’s Law Dictionary (11th
   ed. 2019).

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   determinations de novo and factual findings for clear error. Bowles, 954 F.3d
   at 725; Crawford, 748 F.3d at 256.
          Both the Hospital Agreement and the IMA-PPOplus Agreement
   contain similar “Entire Agreement” provisions.8 Texas law recognizes such
   clauses as “contractual provision[s] stating that the contract represents the
   parties’ complete and final agreement and supersedes all informal
   understandings and oral agreements relating to the subject matter of the
   contract.” Rieder, 603 S.W.3d at 96 (quoting Integration (Merger) Clause,
   Black’s Law Dictionary (11th ed. 2019)).
          The Hospital Agreement, entered nearly a decade after the IMA-
   PPOplus Agreement, does not expressly reference IMA or the IMA-PPOplus
   Agreement. However, it does contemplate that a “Group,” including a
   “third party administrator,” like IMA, would be subject to the Hospital
   Agreement and its arbitration provision.                  Additionally, a “Group
   Agreement” is defined as any agreement “directly or indirectly, between
   [HealthSmart] and a Group.” Contrary to the district court’s conclusion,

          8
              The Hospital Agreement states:
          Entire Agreement: This Agreement, all Exhibits, and other documents
          furnished pursuant to or in furtherance of this agreement and expressly
          made a part hereof shall constitute the entire agreement relating to the
          subject matter hereof between the parties hereto.              Each party
          acknowledges that no representation, inducement, promise or agreement
          has been made, orally or otherwise, by the other party, or anyone acting on
          behalf of the other party, unless such representation, inducement,
          promise, or agreement is embodied in this Agreement, expressly, or by
          incorporation.
          The IMA-PPOplus Agreement states:
          Entire Agreement: This Agreement and all attachments and other
          documents furnished pursuant to this Agreement and expressly made a
          part hereof shall constitute the entire Agreement relating to the subject
          matter hereof between the parties hereto.

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                                          No. 20-20032

   this indicates that IMA (a “Group”) and the IMA-PPOplus Agreement (a
   “Group Agreement”) are incorporated into the Hospital Agreement, and
   thus not barred by its merger clause.
           The converse—that the 2003 IMA-PPOplus Agreement similarly
   incorporates the entirety of the 2012 Hospital Agreement—is not true.
   While IMA agreed to “pay claims of Participating Providers in accordance
   with the applicable Plan and the PPO Contracted Rates,” which means the
   “rates or fees agreed upon by PPO and Participating Provider,” the IMA-
   PPOplus Agreement does not incorporate all of the other, non-payment
   terms in those agreements.9
           Columbia Hospital argues that we disregard IMA’s contractual
   language because the agreements “repeatedly cross-reference each other.”
   It is true that the IMA-PPOplus Agreement contemplates other “Provider
   Agreements”—defined as “any agreement for the provision of Covered
   Services to Beneficiaries that is entered . . . indirectly with an entity
   representing such Participating Provider”—including contracts like the
   Hospital Agreement, which IMA entered indirectly through the Network
   Cross Access Agreement. We agree with IMA, however, that IMA “never

           9
              Columbia Hospital passingly refers to a 2013 provision of the Texas Insurance
   Code which Columbia Hospital says prohibits PPO networks—here, HealthSmart and
   PPOplus—from providing an entity with “access to health care services or contractual
   discounts under a provider network contract unless the provider network contract
   specifically states that the person must comply with all applicable terms, limitations, and
   conditions of the provider network contract.” Tex. Ins. Code § 1458.102(a). Columbia
   Hospital did not raise this argument before the district court, nor does it explain on appeal
   how this provision applies, if at all, to third-party administrators like IMA, or to the
   agreements at issue here, all of which predate the 2013 statute. See Leverette v. Louisville
   Ladder Co., 183 F.3d 339, 342 (5th Cir. 1999) (“This Court will not consider an issue that
   a party fails to raise in the district court absent extraordinary circumstances.”); Cinel v.
   Connick, 15 F.3d 1338, 1345 (5th Cir. 1994) (“A party who inadequately briefs an issue is
   considered to have abandoned the claim.”).

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                                         No. 20-20032

   agreed to comply with or be a party to the ‘Provider Agreements.’” This
   distinction is critical. Moreover, the IMA-PPO Plus Agreement discusses
   “Provider Agreements” only in reference to the obligations imposed on
   PPOplus, not IMA. Instead, the IMA-PPOplus Agreement emphasizes
   IMA’s obligations to pay the “PPO Contracted Rates,” without referencing
   the more expansive obligations of any individual Provider Agreement.10
           Contrary to Columbia Health’s assertions, these obligations are not
   co-extensive. Consequently, like the district court, we decline to construe
   these agreements as a unified contract. See Reider, 603 S.W.3d at 94–95.11
                                              IV.
           For the foregoing reasons, the district court’s denial of Columbia
   Hospital’s motion to compel arbitration is AFFIRMED.

           10
              By contrast, the Hospital Agreement requires “any Group accessing [Columbia
   Hospital]’s rates under this Agreement is contractually bound to [Columbia Hospital] to
   adhere to the terms and conditions of this Agreement.”
           11
              Because we conclude that the contracts cannot be construed together as a single,
   unified contract, we need not consider the district court’s alternative holding that the
   agreements can be deemed unified for reimbursement purposes but not to compel
   arbitration. IMA, Inc., 2019 WL 7168099, at *3 (citing Baylor Univ. Med. Ctr. v. Nippon Life
   Ins. Co., No. CIV.A.3:09CV1496L, 2010 WL 330238, at *4 (N.D. Tex. Jan. 28, 2010)).

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