John McNeill, Jr, R.Ph. And Nichols Southside Pharmacy v. Courtney N. Phillips, Executive Commissioner Sylvia Hernandez Kauffman, Inspector General And Texas Health and Human Services Commission

CourtCourt of Appeals of Texas
DecidedAugust 20, 2019
Docket14-18-00278-CV
StatusPublished

This text of John McNeill, Jr, R.Ph. And Nichols Southside Pharmacy v. Courtney N. Phillips, Executive Commissioner Sylvia Hernandez Kauffman, Inspector General And Texas Health and Human Services Commission (John McNeill, Jr, R.Ph. And Nichols Southside Pharmacy v. Courtney N. Phillips, Executive Commissioner Sylvia Hernandez Kauffman, Inspector General And Texas Health and Human Services Commission) is published on Counsel Stack Legal Research, covering Court of Appeals of Texas primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

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John McNeill, Jr, R.Ph. And Nichols Southside Pharmacy v. Courtney N. Phillips, Executive Commissioner Sylvia Hernandez Kauffman, Inspector General And Texas Health and Human Services Commission, (Tex. Ct. App. 2019).

Opinion

Reversed and Remanded and Majority and Dissenting Opinions filed August 20, 2019.

In The

Fourteenth Court of Appeals

NO. 14-18-00278-CV

JOHN MCNEILL, JR., R.PH.; AND NICHOLS SOUTHSIDE PHARMACY, Appellants V.

COURTNEY N. PHILLIPS, EXECUTIVE COMMISSIONER; SYLVIA HERNANDEZ KAUFFMAN, INSPECTOR GENERAL; AND TEXAS HEALTH AND HUMAN SERVICES COMMISSION, Appellees

On Appeal from the 200th District Court Travis County, Texas Trial Court Cause No. D-1-GN-14-002090

MAJORITY OPINION

In this appeal from an order granting a plea to the jurisdiction and denying a petition for writ of mandamus, appellants John McNeill and Nichols Southside Pharmacy [collectively, “McNeill”] complain (1) he should receive a contested case hearing to challenge the results of an administrative agency’s audit, (2) the agency failed to comply with a valid Rule 11 agreement, and (3) the agency completed its audit using a faulty extrapolation methodology. We reverse the trial court’s grant of the appellees’ plea to the jurisdiction and remand this case to the trial court for further proceedings to determine whether the process provided to McNeill comports with clearly established Due Process jurisprudence concerning administrative takings.

BACKGROUND

McNeill entered into a contract with the Texas Health and Human Services Commission [“Commission”] to provide prescription drugs under Medicaid and the Vendor Drug Program. According to the plain language of the contract, McNeill agreed to comply with “the applicable requirements of the Medicaid and Vendor Drug Programs.” One such requirement was that McNeill’s pharmacy would have to submit to periodic performance audits.

The Commission audited McNeill’s pharmacy and concluded it overpaid by $70,266.36. The Commission calculated that figure by examining certain errors within a three-year period that were discovered from a random sampling of billing records and extrapolating the alleged overpayment from those errors. In a response to the draft audit report, McNeill challenged the Commission’s extrapolation methodology and underlying factual assumptions. After receiving McNeill’s response, the Commission revised its audit report and reduced the amount of the alleged overpayment to $69,911.48. The Commission also advised McNeill he had a right to appeal the audit results under Title 1, Section 354.1891(c) of the Texas Administrative Code.1

1 The applicable version of that regulation provides as follows: “If a provider disagrees with the initial findings of an audit, the provider may present additional documentation to the Commission’s auditor for review. Also, on written request, the Commission provides an opportunity for audit resolution for a provider who wants to present documentation not available 2 McNeill invoked his right of appeal and the Commission scheduled an informal hearing to discuss the audit exceptions that were still challenged. After the hearing, the Commission sent a “Final Notice” advising McNeill that the amount of the overpayment had been reduced to $64,549.30. The Commission did not mention any additional right to appeal and advised that McNeill should arrange for payment within thirty days or a vendor hold would be imposed.

Citing Section 531.1201 of the Texas Government Code, McNeill then asked the Commission to docket a contested case hearing before the State Office of Administrative Hearings [“SOAH”].2 The Commission responded that it would not do so.

McNeill promptly renewed his request for a contested case hearing under Section 531.1201 and invoked appellate provisions applicable to administrative actions and sanctions. In response to McNeill’s renewed request, the Commission explained he was not entitled to a hearing under Section 531.1201 because that statute applies to cases “arising out of a fraud or abuse investigation,” whereas McNeill’s case arose out of a performance audit. The Commission also explained McNeill’s reliance on other cited regulations was misplaced because they did not control over Rule 354.1891(c) (which applies specifically to audits).

at the time of audit. If the provider still disagrees and wants to appeal, the Commission, upon receipt of written request to the Manager of Contracts and Rebates, provides either an informal hearing or additional desk review.” 1 Tex. Admin. Code Ann. § 354.1891(c). 2 The applicable version of that statute provides as follows: “A provider must request an appeal under this section not later than the 15th day after the date the provider is notified that the commission or the commission’s office of inspector general will seek to recover an overpayment or debt from the provider. On receipt of a timely written request by a provider who is the subject of a recoupment of overpayment or recoupment of debt arising out of a fraud or abuse investigation, the office of inspector general shall file a docketing request with the State Office of Administrative Hearings or the Health and Human Services Commission appeals division, as requested by the provider, for an administrative hearing regarding the proposed recoupment amount and any associated damages or penalties.” Tex. Gov’t Code Ann. § 531.1201(a).

3 When McNeill failed to pay the demanded restitution within the allotted time frame, the Commission requested a vendor hold. McNeill then filed suit against the Commission, its executive commissioner, and its inspector general [collectively, the “Defendants”] seeking declaratory and mandamus relief.3

McNeill also moved for a temporary restraining order and alleged Defendants were withholding more than the amount of the claimed overpayment. During the hearing, McNeill produced evidence that $96,000.00 was currently subject to the vendor hold, an amount in excess of the alleged overpayment of $64,549.30. When the trial court indicated that the excessive withholding was unauthorized,4 the parties entered into a Rule 11 agreement promising Defendants would “release any amount above $64,531.30 from the vendor hold” within ten days. The parties further agreed the Rule 11 agreement “would remain in place during the pendency of this case, pending further orders of the court.”

Eight months later, McNeill moved to enforce the Rule 11 agreement and alleged the amount of payments subject to the vendor hold still exceeded the amount of the alleged overpayment. The record does not reveal a ruling on this motion.

McNeill then amended his pleadings and Defendants asserted sovereign immunity in a plea to the jurisdiction. McNeill filed a response and the trial court conducted a hearing (but declined to rule). Instead, it took the plea to the jurisdiction under advisement and proceeded to a non-jury trial on the merits.

3 At the time of suit, the executive commissioner was Kyle Janek and the inspector general was Douglas Wilson. Because Janek and Wilson no longer occupy the public offices in which they were sued, we have substituted their names in the style of this appeal with the current officeholders. See Tex. R. App. P. 7.2. 4 The trial court referred to a regulation that states “a vendor hold placed due to a failure to pay restitution within the allotted time period . . . will be lifted when restitution is paid in full.” See 1 Tex. Admin. Code § 354.1813(c)(2).

4 McNeill was the only witness who appeared at the trial (other than his attorney, who testified about her attorney’s fees). McNeill testified about various topics, including how Defendants (1) conducted their audit, (2) used a non- representative sample when performing their extrapolation analysis, (3) have since changed their extrapolation methodology, and (4) wrongly flagged invalid prescriptions in their audit.

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John McNeill, Jr, R.Ph. And Nichols Southside Pharmacy v. Courtney N. Phillips, Executive Commissioner Sylvia Hernandez Kauffman, Inspector General And Texas Health and Human Services Commission, Counsel Stack Legal Research, https://law.counselstack.com/opinion/john-mcneill-jr-rph-and-nichols-southside-pharmacy-v-courtney-n-texapp-2019.