ACS Primary v. UnitedHealthcare ( 2023 )

Case: 21-20168 Document: 00516648657 Page: 1 Date Filed: 02/16/2023
United States Court of Appeals
for the Fifth Circuit
United States Court of Appeals
Fifth Circuit
FILED
February 16, 2023
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:
We previously certified a question to the Texas Supreme Court asking
whether the Texas Insurance Code’s Emergency Care Statutes authorize a
private cause of action. After receiving a response in the negative, we
REVERSE the judgment below.
Case: 21-20168 Document: 00516648657 Page: 2 Date Filed: 02/16/2023
No. 21-20168
I.
In Texas, hospital employees may not deny individuals emergency
care due to their inability to pay. Tex. Health & Safety Code Ann.
§§ 241.027(b)(5), 241.028(c)(2), 311.022(a)–(b). This raises the prospect
that physicians will treat patients who are either uninsured or whose
insurance does not cover such treatment. To ease the economic burdens
associated with this care, the Texas Insurance Code requires that insurance
companies insuring patients who receive emergency treatment by out-of-
network healthcare providers reimburse those providers at their “usual and
customary rate” or an agreed rate (the “Emergency Care Statutes”). Tex.
Ins. Code Ann. §§ 1271.155(a), 1301.0053(a), 1301.155(b).
Since January 2016, Plaintiffs-Appellees, emergency care physician
groups in Texas (the “Plaintiff Doctors”), have provided various emergency
medical services to patients enrolled in health insurance plans insured by
Defendants-Appellants UnitedHealthcare Insurance Company or
UnitedHealthcare of Texas, Incorporated (collectively, “UHC”). The
Plaintiff Doctors are not within UHC’s provider network. In their operative
complaint, the Plaintiff Doctors allege (among other claims) that UHC has
failed to remit the “usual and customary rate” for the emergency care that
the Plaintiff Doctors provide to patients insured by UHC in violation of the
Emergency Care Statutes. UHC moved to dismiss the Plaintiff Doctors’
complaint, which was denied in part by the district court. Specifically, the
court rejected UHC’s argument that the Emergency Care Statutes did not
authorize a private cause of action. The court also held that the Plaintiff
2
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No. 21-20168
Doctors’ claim under the Emergency Care Statutes was not otherwise
preempted by the Employee Retirement Income Security Act (“ERISA”). 1
UHC immediately sought interlocutory review of two issues: (1)
whether the Emergency Care Statutes authorize an implied private cause of
action, and (2) whether the Plaintiff Doctors’ claim under the Emergency
Care Statutes is otherwise preempted by ERISA. Both the district court and
this circuit granted UHC’s request for interlocutory review. The Plaintiff
Doctors subsequently moved to certify the first issue—whether the
Emergency Care Statutes provide for a private cause of action—to the Texas
Supreme Court. In February 2022, we granted the Plaintiff Doctors’ motion
and certified the following question to the Texas Supreme Court:
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?
ACS Primary Care Physicians Sw., P.A. v. UnitedHealthcare Ins. Co., 26 F.4th
716, 720 (5th Cir. 2022). 2
II.
In January 2023, the Texas Supreme Court answered the certified
question in the negative, holding that the Texas Insurance Code “does not
create a private cause of action for claims under the Emergency Care
Statutes.” Texas Med. Res., LLP v. Molina Healthcare of Tex., Inc., No. 21-
1
The district court, however, dismissed the Plaintiff Doctors’ other claims for
breach of an implied-in-fact contract and quantum meruit, which are not at issue on appeal.
2
We withheld judgment on the second issue before us on interlocutory review:
whether the Plaintiff Doctors’ claim under the Emergency Care Statutes was preempted
by ERISA.
3
Case: 21-20168 Document: 00516648657 Page: 4 Date Filed: 02/16/2023
No. 21-20168
0291, 2023 WL 176287, at *8 (Tex. Jan. 13, 2023). Therefore, the Plaintiff
Doctors’ claim for violation of the Emergency Care Statutes must be
dismissed. Because there is no private cause of action under the Emergency
Care Statutes, the second issue before us—whether the Plaintiff Doctors’
claim under the Emergency Care Statutes is otherwise preempted by
ERISA—is now moot. Accordingly, we REVERSE the district court’s
judgment denying UHC’s motion to dismiss the Plaintiff Doctors’ claim for
violation of the Emergency Care Statutes and REMAND for further
proceedings not inconsistent with this opinion.
4