Robert S. Howell, D.C. First Rio Valley Medical, P.A. Keith Gilbert William Maxwell And Gilbert & Maxwell, P.L.L.C. v. Texas Workers' Compensation Commission Envoy Medical Systems, L.L.C. Texas Mutual Insurance Company State Office of Risk Management and Continental Casualty Insurance Company

Court of Appeals of Texas·Decided August 12, 2004·No. 03-03-00381-CV·Published

Opinion

TEXAS COURT OF APPEALS, THIRD DISTRICT, AT AUSTIN

NO. 03-03-00381-CV

Robert S. Howell, D.C.; First Rio Valley Medical, P.A.; Keith Gilbert; William Maxwell; and Gilbert & Maxwell, P.L.L.C., Appellants

v.

Texas Workers’ Compensation Commission; Envoy Medical Systems, L.L.C.; Texas Mutual Insurance Company; State Office of Risk Management; and Continental Casualty Insurance Company, Appellees

FROM THE DISTRICT COURT OF TRAVIS COUNTY, 201ST JUDICIAL DISTRICT NO. GN200967, HONORABLE W. JEANNE MEURER, JUDGE PRESIDING

OPINION

In this case, we must decide whether, when a health care provider provides medical

treatment to a workers’ compensation claimant and subsequently disputes the adequacy of payment

by a workers’ compensation insurance carrier, the health care provider must first exhaust

administrative remedies within the workers’ compensation system before seeking to resolve the

dispute in a court. We must also determine whether, after one party files a declaratory judgment

action in a Travis County district court, that court obtains jurisdiction to grant a counterclaimant’s

request for an anti-suit injunction prohibiting the original party from pursuing related suits in the

courts of another Texas county. Appellants Robert S. Howell, D.C. and First Rio Valley Medical, P.A. (collectively,

“First Rio”) appeal a judgment rendered in favor of appellees Texas Workers’ Compensation

Commission; Envoy Medical Systems, L.L.C.; Texas Mutual Insurance Company; State Office of

Risk Management; and Continental Casualty Insurance Company. The district court rendered

judgment that First Rio must first exhaust administrative remedies before seeking judicial review

of a dispute with a carrier and that the independent review organization (“IRO”) fees for medical

necessity reviews are constitutional. Pursuant to the declaratory action, the district court awarded

attorney’s fees to the Commission, Texas Mutual, and Continental Casualty.1 The district court

further enjoined First Rio from prosecuting the approximately 723 billing dispute lawsuits that it had

filed in Cameron County and from filing a new lawsuit until it has received a final, non-appealable

decision in its favor through the administrative process and the carrier has refused to pay.

In nine issues, First Rio asserts that (i) the district court was without jurisdiction to

enter the anti-suit injunction; (ii) the district court erred in finding that First Rio, when disputing

adequacy of payment, must exhaust administrative remedies within the workers’ compensation

system before seeking review in a court; (iii) the district court abused its discretion in denying First

Rio’s demand for a jury trial; (iv) the district court erred in granting declaratory relief because the

declaratory action was an improper vehicle for attorney’s fees; (v) the district court erred in granting

declaratory relief because it was an improper advisory opinion; (vi) the district court erred in finding

that Dr. Howell is a proper party to appellees’ counterclaims; (vii) some of the district court’s rulings

1 The district court also awarded attorney’s fees to other entities who are not parties to this appeal.

2 violated the United States and Texas Constitutions; (viii) the district court erred in finding that First

Rio and Dr. Howell are vexatious litigants; and (ix) the district court erred in finding that the IRO

fee is constitutional. We do not find any error pertaining to these issues.

In a separate issue, appellants Keith Gilbert, William Maxwell, and Gilbert &

Maxwell, P.L.L.C. (collectively, “the law firm”), counsel for First Rio, assert that the district court

abused its discretion by twice imposing sanctions on them. The district court first imposed $13,000

in sanctions pursuant to Texas Mutual’s motion for sanctions and second sua sponte imposed $3,200

in sanctions after counsel for First Rio did not appear at the hearing on the motion for judgment. As

to Texas Mutual’s motion for sanctions, because we affirm the grounds for the sanctions only in part,

we remand the issue for recalculation of attorney’s fees sanctions in accordance with this opinion.

As to the $3,200 award, although the district court did not afford the law firm an opportunity for

notice and hearing before imposing those sanctions, the law firm failed to preserve error by not

affording the district court an opportunity to correct its mistake.

Because only the Commission and the State Office of Risk Management sought

permanent injunctive relief, and pursuant to Continental Casualty’s request, we reform the judgment

to delete the reference to Continental Casualty as one of the parties seeking a permanent injunction.

We affirm the judgment in all other respects.

FACTUAL AND PROCEDURAL BACKGROUND

Changes to Commission’s Administrative Review Process

First Rio’s causes of action arise from the 2002 changes in the Commission’s

administrative review of an insurance carrier’s denial or reduction in payment of a medical bill. To

3 put the events giving rise to this case in context, we will begin with some background concerning

the 2002 amendments.

When a health care provider seeks payment from an insurance carrier for treatment

of a workers’ compensation claimant, it must first submit the medical bill to the carrier. 28 Tex.

Admin. Code § 134.801(a) (2004).2 If the carrier denies or reduces the payment and the health care

provider is dissatisfied with the carrier’s action, the health care provider is entitled to a review of the

medical service. Tex. Lab. Code Ann. § 413.031(a)(1) (West Supp. 2004). Before pursuing further

action, the health care provider must first send a request for reconsideration to the carrier. 28 Tex.

Admin. Code § 133.304(k), (m) (2004). If still dissatisfied with the carrier’s action, the health care

provider may request medical dispute resolution. Id. § 133.304(m). The Commission shall by rule

establish “a program for . . . resolution of a dispute regarding health care treatments and services.”

Tex. Lab. Code Ann. § 413.013(1) (West 1996).

Until January 1, 2002, the Commission’s medical review division handled all medical

dispute resolution matters, falling into two categories: medical fee disputes and medical necessity

disputes. See 25 Tex. Reg. 2128 (2000) (codified at 28 Tex. Admin. Code § 133.305) (adopted Mar.

10, 2000). After that date, pursuant to House Bill 2600 passed in the 2001 legislative session, IROs

began to conduct medical necessity reviews of health care provided to workers’ compensation

2 Unless an amendment of a provision made after this suit arose affects our analysis, or unless citation to historical provisions is necessary, for convenience we will refer to the current statutory and administrative provisions.

4 claimants.3 The medical review division continued to handle medical fee disputes. See 28 Tex.

Admin. Code § 133.307 (2004).

IROs were created in 1997 to perform reviews of medical necessity in disputes

between medical insurance carriers and persons insured by employer-provided health benefit plans.4

The Texas Department of Insurance regulates IROs. Tex. Ins. Code Ann. art. 21.58C (West Supp.

2004).

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Robert S. Howell, D.C. First Rio Valley Medical, P.A. Keith Gilbert William Maxwell And Gilbert & Maxwell, P.L.L.C. v. Texas Workers' Compensation Commission Envoy Medical Systems, L.L.C. Texas Mutual Insurance Company State Office of Risk Management and Continental Casualty Insurance Company, (Tex. Ct. App. 2004).

Robert S. Howell, D.C. First Rio Valley Medical, P.A. Keith Gilbert William Maxwell And Gilbert & Maxwell, P.L.L.C. v. Texas Workers' Compensation Commission Envoy Medical Systems, L.L.C. Texas Mutual Insurance Company State Office of Risk Management and Continental Casualty Insurance Company (Robert S. Howell, D.C. First Rio Valley Medical, P.A. Keith Gilbert William Maxwell And Gilbert & Maxwell, P.L.L.C. v. Texas Workers' Compensation Commission Envoy Medical Systems, L.L.C. Texas Mutual Insurance Company State Office of Risk Management and Continental Casualty Insurance Company) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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