ACCEPTED 01-13-01034-CV FIRST COURT OF APPEALS HOUSTON, TEXAS 1/20/2015 6:54:13 PM CHRISTOPHER PRINE CLERK
NO. 01-13-01034-CV
In the Court of Appeals FILED IN 1st COURT OF APPEALS for the First Judicial District HOUSTON, TEXAS Houston, Texas 1/20/2015 6:54:13 PM CHRISTOPHER A. PRINE Clerk
SHIRLEY LENOIR, INDIVIDUALLY AND AS PERSONAL REPRESENTATIVE OF THE ESTATE OF SHANA LENOIR AND CHRISTOPHER MCKNIGHT, INDIVIDUALLY AND AS NEXT FRIEND OF NAYLA MCKNIGHT Appellants, VS.
LEAH ANN GONSKI MARINO F/K/A LEAH ANNE GONSKI AND JAOU-CHEN HUANG, M.D.
Appellants.
On Appeal From the 164th Judicial District Court of Harris County, Texas Trial Court Cause No. 2012-35806A The Honorable Alexandra Smoots-Hogan, Judge Presiding
APPELLANTS’ MOTION FOR REHEARING
TO THE HONORABLE FIRST COURT OF APPEALS:
Appellants, Shirley Lenoir, Individually and as Personal Representative of
the Estate of Shana Lenoir and Christopher McKnight, Individually and as next
friend of Nayla McKnight, pursuant to TEX. R. APP. P. §52.9, file this motion for
rehearing of that portion of the Court’s opinion, issued on November 25, 2014,
Page 1 of 8 affirming the trial court’s dismissal of Appellee Jaou-Chen Huang under TEX. CIV.
PRAC. & REM. CODE §101.106 (f).
I.
The Lenoirs filed a lawsuit against Dr. Huang in his individual capacity
because they alleged that his violations of state law proximately caused Shana
Lenoir’s death. In the Court’s opinion regarding Dr. Huang, the Court stated,
“Lenoir does not dispute that the Health Science Center is a governmental unit.
What she challenges is whether Dr. Huang was acting within the scope of his
employment with the Health Science Center when he oversaw Dr. Gonski’s care of
Lenoir.” Op. at 22.
While it is true that the Lenoirs challenged whether Dr. Huang was in the
scope of his employment for UTHSCH, the Lenoirs also challenged whether Dr.
Huang was acting as UTHSCH’s employee at the time of the incident in question.
See, Appellants’ Brief at 28-44. An alleged governmental employee has the burden
to establish—as a matter of law—that he is an employee of a governmental unit
and evidence that is disputed or insufficient cannot support a dismissal. Op. at 8.
However, the Court’s opinion does not discuss Dr. Huang’s status as an
employee of a governmental unit, even though the issue is hotly contested by the
Lenoirs. As defined by TEX. CIV. PRAC. & REM. CODE §101.001(2):
“Employee” means a person, including an officer or agent, who is in the paid service of a governmental unit by competent authority, but Page 2 of 8 does not include an independent contractor, an agent or employee of an independent contractor, or a person who performs tasks the details of which the governmental unit does not have the legal right to control.
Dr. Huang offered two affidavits in support of his argument that he was
acting as an employee of UTHSCH at the time of the incident. CR 333-334, 803-
807. No exhibits are attached to these affidavits or referenced in the affidavits.
The Lenoirs objected that statements in these affidavits were conclusory and were
contradicted by other evidence, including Dr. Huang’s contract with UT
Physicians, but the Court overruled these objections. Op. 26-28.
In City of Keller v. Wilson, 168 S.W. 3d 802, 812 (Tex. 2005), the Court
discussed the rule that incompetent evidence is legally insufficient to support a
judgment, even if admitted without objection. The Court stated, “[Evidence
showing it to be incompetent cannot be disregarded, even if the result is contrary to
the verdict. If the rule were otherwise, incompetent evidence would always be
legally sufficient, because the evidence showing it to be incompetent could never
be considered.” The Court then gave the following example of when evidence is
legally insufficient:
Similarly, an employee's testimony that he was in the course and scope of his employment is legally insufficient to support a verdict against his employer if the evidence shows that legal conclusion to be incompetent. Id.
Page 3 of 8 Thus, Dr. Huang’s statements that he was an employee of UTHSCH at the
time of the incident are incompetent legal conclusions that cannot support his
dismissal, if the statements are contradicted by other evidence.
UT Physicians (formerly Uni Care Plus) is a Texas certified non-profit
health corporation which is regulated by TEX. OCC. CODE §162.001, et seq. CR
1046. Dr. Huang was working at a UT Physicians’ clinic at the time of the
incident performing medical services for professional fees. Dr. Huang signed a
written contract with UT Physicians to work at the facility. CR 1046-1062. UT
Physicians had the right to terminate Dr. Huang’s practice at its facility. CR 1049-
1050. Dr. Huang agreed to comply with UT Physicians’ conditions of employment
listed in the contract, including the requirement that he provide only “Medically
Necessary” medical services and comply with UT Physicians’ bylaws. CR 1046-
1049. The contract expressly states, “Participation in University Care Plus (now
U.T Physicians) has no effect on or relationship to faculty status at UT-H or
medical staff privileges at any hospital…”. CR 1049 at D.1 (“Effect of
Participation in University Care Plus”). More importantly for the Lenoirs’ claim
against him, Dr. Huang agreed to comply with UT Physicians’ billing policies and
to submit claims for his professional services using UT Physicians’ billing forms.
CR 1048, at ¶¶8-9. There is no mention of Dr. Huang supervising residents in the
UT Physicians’ contract and the Lenoirs have disputed that UT Physicians is a part
Page 4 of 8 of the UTHSCH residency training program. See, Appellants’ Brief regarding Dr.
Gonski.
Thus, UT Physicians had the legal right to control the details of Dr. Huang’s
work at its facility that the Lenoirs allege caused their decedent’s death, not
UTHSCH. Dr. Huang cannot claim he is entitled to governmental immunity
because of his faculty status at UTHSCH when the contract he signed to work at
the UT Physicians’ clinic says that the work is unrelated to his faculty status at
UTHSCH.
Finally, this Court rejected the Lenoirs’ ultra vires argument stating that
more recent case law indicates that an employee is within his scope of
employment, even if acts wrongly or negligently. However, the Lenoirs also cited
City of El Paso v. Heinrich, 284 S.W.3d 366 (Tex. 2009) in support of their ultra
vires argument. In Heinrich, the Texas Supreme Court stated, “[A]n action to
determine or protect a private party's rights against a state official who has acted
without legal or statutory authority is not a suit against the State that sovereign
immunity bars.” Id. at 368, quoting Fed. Sign v. Tex. S. Univ., 951 S.W.2d 401,
405 (Tex.1997). The Court also recognized a cause of action for money damages
against a government official in his individual capacity for wrongful or
unconstitutional conduct. Id. at 373, n. 7. Since the Court does not discuss
Page 5 of 8 Heinrich in its opinion, it is unclear why this case is not applicable to authorize the
Lenoirs’ claim.
PRAYER
For the reasons set forth above, Appellants respectfully request that this
Court rehear its opinion regarding Dr. Huang and upon rehearing, reverse the trial
court’s ruling dismissing Dr. Huang and remand this case for further proceedings
and grant Appellants all other relief to which they may be entitled.
Respectfully submitted,
THE GOURRIER LAW FIRM, PLLC
By: /s/ Joseph M. Gourrier JOSEPH M. GOURRIER Texas State Bar No. 24007258 530 Lovett Boulevard, Suite B Houston, Texas 77006 joseph@gourrierlaw.com Telephone: 713-533-9077 Facsimile: 713-533-9376 ATTORNEY FOR APPELLANTS
CERTIFICATE OF COMPLIANCE
As required by Texas Rule of Appellate Procedure 9.4(i)(3), Appellants certify that this brief is 1,061 words which is in compliance with Texas Rule of Appellate Procedure 9.4(i)(2).
By: /s/ Joseph M. Gourrier JOSEPH M. GOURRIER Texas State Bar No. 24007258
Page 6 of 8 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing document has been forwarded to all known counsel of record in this cause in accordance with the Texas Rules of Civil Procedure via U.S. Mail, certified, return receipt requested, e- service, and/or facsimile and/or hand delivery, on this 20th day of January 2015.
Charles B. Holm John R. Strawn, Jr. Kyle M. Smith Victoria P. Skinner Holm Bambace, LLP Pennzoil Place, South Tower 1010 Lamar, Suite 1100 711 Louisiana, Suite 1850 Houston, Texas 77002 Houston, Texas 77002 Telephone: (713) 652-9700 Telephone: (713) 659-9600 Facsimile: (713) 652-9702 Facsimile: (713) 659-9601 Attorneys for Defendants Leah Ann Attorneys for Defendant Leah Ann Gonski Marino f/k/a Leah Anne Gonski Marino f/k/a Leah Anne Gonski and Jaou-Chen Huang, M.D. Gonski
/s/ Joseph M. Gourrier Joseph M. Gourrier
Page 7 of 8
Acknowledgment of Physician Participation in University Care Plus (Dr. Huang’s Contract with U. T Physicians) .................................................................................... Tab 1
Page 8 of 8 TAB 1
i, Ju -'C,4e (ILt&h16 çPhysiciaifl acknowledge and understand.the conditions for participation in University Cam Phis ru'uvsity Care Plus'), a Texas certified non-profit medical corporation, which has entered into an agreement with The University of Texas Health Science Center of Houston ("UT-W) pursuant to which I and other faculty physicians will participate in the professional activities of University Care Plus. By my signature below, I acknowledge that I am bound by the participation requirements herein.
A. Pu rPOSK of tTnkBrsty Calm Ph i s. University Can Plus is a non-profit organization of physicians which has as its purposes:
1. To function as a. physician organization to arra4e for the provision of medical services by its participating physicians;
2. To support the provision of quality, cost-effective medical services and the development of new services and products for the community;
To more effectively market the medical services provided by its participating physicians to third party payors and the community;
4. To accomplish all objectives through the joint, cooperthve action of its participating physicians; and
5. To transact any and all other business which a Texas non-profit medical corporation Sy do.
B. ObligafloinatTTth,prity CirtVl. University Care Plus agrees to units beat efforts to negotiate and enter into agreements with potential third-party payors Ccrouo Contracts"), including employers, insurance companies, health benefit and managed care plans, in order to enable Thñversfty Care Plus to arrange for the delivery of health: care services to patients covered under Group Contracts (&MenzberC) by its participating physicians, including Physician. University Care Plus shall also satisfy such other criteria as the Board of Directors may from time to time determine.
C. Cnnvflttanc at P'r4t.r4pattnn. Physician understands and agrees to comply with the following conditions of participation, which apply to all participating physiói2th of University Care Plus:
I.. To participate in and provide Physician's usual range of medical services under any and all Group Contracts with which University Care Plus contracts that require the Physician's participation (recognizing and agreeing to the fact that not all contracts may request or, require that Physician be included In the panel of contracting providers) and that
EtT$WAL4ZJ/2768fl HIBIT
1046 conform to the Fee Schedule agreed to by UT-H (Attwhrne.tt A') and/or that are otherwise executed by University Care Plus in accordance with Section F of this Agreement;
2. To accept Members as long as Physician's practict is open to new patients in general, unless IThH provides University Can PM with thirty (30) days • written notice that Physician is closing his or her practice to all new • patients. In the event of such notice by UTH. Physician. may not accept any new Members. Physician may reopen his or her practice to new Members upai thirty (30) days written notice by UT-H to University Care Plus, after which Physician shall again accept Members under all Group Contracts then in effect.
To provide or arrange for the provision of Medically Necessary services required by Members which Physician customarily provides to his at her other patients and in accordance with. the standards and procedures applicable to Physician's other patients. For purposes of this Agreement, Itflcally Necessary' means those health are services that, in accordance with applicable utilization management policies of University Care Plus and/or a payor, are determined to be
(a) appropriate for the symptoms and diagnosis or treatment of the Member's condition, illness, disease orinjury ) provided for the diagnosis, or the direct care and treatment of the Member's condition, illness, disease or injury;
(c) in accordance with current standards of good medical practice;
(d) not primarily for the convenience of the Member or Physician; and (e) the moat appropriate supply or level of service that can safely be provided to the Member.
When applied to hospitalization, this further means that the Member requires acute rat an inpatient due to the nature of the services rendered or the Member's condition, and the Member cannot receive safe or adequate care as an outpatient 4. If required by a particular Group Contract, to admit or refer only to providers affiliated with University Cam Plus, except in the even: of an emergency or when services or facilities are not available from such providers;
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1047 5. To provide or make medical coverage available and accessible twenty-four hours a day, seven days a week for Members requiring urgent or emergency services;
6. To maintain a level of clinical activity as appropriate to Physician's practice specialty and at such hospital(s) or clinics designated :by University Care Plus' Board sufficient to allow University Care Plus to àbjcctively measure the cost, utilization and quality Of services provided to Members;
7. To comply with the Bylaws of University Care Plus and all other policies and procedures. of University Care Plus that have been or will be enacted by University Care Plus' Tha4 (and any amendments thereto), including. but not limited to Participation Criteria (Attnehment R), Antitrust Policy (A1tacbmti4C), and this Agreement;
8. To comply with the requirements of the utilization management, cStialing, claims payment adinhiirnzdon,. billing) verification, coordination of benefits and quality improvement programs (and any amendments thereto) of University Care Plus and Group Contracts upon provision of copies of such documents to Physician;.
9. To submit an itented claim for Physician's sezvices using the RCPA- 1500 billing form, or a form containing equivalent information, within the time frame required by the Board pursuant to various contracts for completion of the Member's course of treatment;
10. To allow University Care Plus to publish Physician's name, specialty, address and telephone number in University Care. Plus' and Group Contracts' marketing materials;
11. To wo& cooperatively with other physicians, health professionals, the staff of University Care Plus in order to perform the Thnctions, duties and obligations required by Group Contracts, University Cart Plus Bylaws, and this Agreement;
12. To address all grievances relating to University . Cut fl 1 internal operations through the Grievance Policy adoptS by University Care Plus
13. . To comply with the participation renewal requirements and procedures utilized by University Care Pius;
14. To agree that Physician's voluntary cancellation of his/herpanicipatian in University Care Plus requires both ninety O) days notice to the University Care Plus Board of Directors, written approval by UT-H and compliance with the tcnninadon provisions of all managed care agreements into which Physician has entered; and
15. To advise University Care Plus immediately upon any change in the information provided in Physician's application for University Care Plus, - including but not limited to conflicts of interest the Physician has or may
D. fltert at rttt4pntInn in Thdvswcity r2n Phis Physician has reviewed the Bylaws and policies of University Care Plus and understands and agrees that:
1. Participation in University Care Plus has no effect on or relationship to faculty Uamz at UT-B or medical staff privileges at any hospital, except that loss of faculty status at UT-H or medical smif privileges results in termination of University Can Plus participation in accordance with • Section Eof this Agreement',
2. Participation is not transferable, and no individual may sell, assign, transfer or convey his or her Physician participation in University Care Plus to any other person at any other time;
3. In no event shall any Physician bill, charge, collect a deposit from, seek compensation, rtmunolion or reimbursement from or have any recourse against any Member except as expressly permitted by and in accordance with applicable Group Contracts or payor policies, such as for Member deductibles and/or copayments. -
4. Stequit to Physicià&s execution of this Agreements Physician shall not independently contract with any party with whom University Care Plus holds a Group Contract for those services and/or products covered by University Came Plus' Group Contract
5. Nothing shall prohibit Physician from providing on an individual basis any medical services not subject to a Group Contract to any patient, or from providing medical services of any type to any patient who is not covered under any Group Contract.
E. Tn,nnntnn 4 Psit{4ittan. Physician understands that the following actions shall cause the Board to taminate Physician's participation in University Care Plus:
1. Upon Physicians departure or resignation from the faculty of UT-H or retirement from the active practice of medicine, VT-H shall so notify Unity Cue jjn .andPhysician's participation in University Care Plus shall be automatically terminated upon the date spcci$ed by University Care Plus' Board or its designee.
1049 2. Physician's participation in University Care Plus shall be terminated immcdiate3y in the event that Physician ceases to be duly licensed to practice medicine in the State of Texas.
3. Physician's participation shall be automatically terminated if Physician ceases for whatever reason to maintain appropriate privileges at the hospital(s) designated by University Care Plus' Board.
4. The Board of Directors may terminate Physician's participation in University Care Plus for Physician's failure to comply with the requirements of any Group Contracts, this Agreement, the Bylaws of University Care Plus or any policy adopted by the Board.:
5. Physician and UT-H shall be notified by University Care Plus' BeanS or 115 designee in writing of his or her sure to comply with any University Care Plus or Group Contract programs, criteria, or policies and procedures. University Care Plus' Board or its designee shall determine in its sole discretion and shall state in the notice to Physician the number of days in which to remedy such non-compliance. If Physician does not resolve such issues, PhysiSfs panicipadon shall be terminated effective on the date set forth in the notice.
6. The dissolution or bankruptcy of University Cart Plus.
7. Upon termination of this Agreement for any reason. Physician shall continue to provide Medially Necessary services to all Members currently under active freabnent by Physician an the date of wmtinatiod until (a) such • Member's care is transferred to another participating physician, (b) treatment is completed, or (c) for a period of three months, whichever occurs first
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Pursuant to the provisions of the agreement between University Care Plus and 13T-H regarding beulty physicians, participatiân in University Care Plus and subject to the limitations set forth below, Physician hereby constitutes, and appoints University Care Plus as Physician's tne and lawful atney-in-fact for the limited purposes of negotiating and executing Group Conttt1i on behalf of Physician, as well as modifications, extensions and renewals of such Group Contracts, all of which shall be binding upon Physician. Physician thither designates Univasity Care Plus ,as Physician's true and lawflul agent for the further limited purpose of giving, and receiving notices required or permitted to be given and received under such Group Contncts, including nodcas of termSflon. Any notice received by University Care Plus on behalf of Physician shall promptly be txaxsrnitted to Physician.
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1050 2. University Care Plus authority to act as Physicians ittorney-in-fact and agent, as authorized by this Section, is limited by the following conditions and requirements:
(a) University Care Plus shall not execute, nor shall Physician be bound by, any Group Contract that conforms to the Fee Schedule in Atbrhment A, unless at least thirty (30) days after execution of such Group Contract, University Case Plus notifies UT-H and Physician in writing of the content of such Group Contract
(b) University Care Plus shall not execut*, nor shall Physician be bound by, any Group Contract that obligates PitysiClait it provide services ata compensation rate t than that contained in the Pee Schedule in At1ehme* A, unless at len thirty (30) diys prior to such lesser • cotnpeaficn am becoming effective, University Care Plus notifies UT-H and Physician in writing of such lesser compensation raze, • and during suck thirty M day period, neither Physician nor UT-H notifies University Can Plus in writing of an objection to such lesser compensation a
(c) University Care Plus shall not aicecwe, nor shall Physician be bound by, any modification, extension or renewal of any existing Group Contract in which Physician is a wticipant that in any material respect changes the. rights and oblizations of Physician, unless at least thirty (30) days prior to the same becoming effective, University Cart Plus notifies UT-H and Physician, in writing of Such modification, extent or renewal, and during such thirty (30) day period, neither Physician nor UT-H notifies University Care Plus in writhrg of an objection to such modification, extension or renewal.
3, Whenever Physician is required by this Article to itotify tlniversfty Care Plus in writing of any objection to the content of a Group Cohuact, a modification, extension or renewal thereof;, or any decrease in compensation, and Pbytidn fails to do so within the specified 30-day period, Physician shall be conclusively presumed 10 have approved, and University Care Plus shall be conclusjvdyiuthorized to bind Physician to, thflame.
4. This power of attorney and special agent appointznentisgranted for the term of this Agreement, and for any renewal term hereof, and shall be revoked effective upon the termination of this Agreement. G. rnSWnthThy. Physician hereby Thither acknowledges and agrS that Physician will maintain in cuffidence the terms of this Agreement and any payor agreements, including but
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1051 not Limited to fee schedules thereof, as well as all business information that may Caine into Physician's possession by virtue of Physician's status as a participating physician in University Care Plus or an investor, partner, contractor, or supplier of any veniuredeveloped or managed by University Care Plus and will not ditiose any such information to any person other than other participating physicians of University Can Plus or the applicable venture absent a release or a consent to release of such information by University Care Plus or the applicable venwzt
EL Inde Nnnn Neither party shall utilize any trade name, service mark, or any material or property protected by patent trademark, or copyright of the other party except as expressly permitted by this Agreement or otherwise in writing.
L Nthi. Any notice required under this Agreement shall be in writing and sent by certified or registered mail, return receipt requested, postage prepaid, by express mail, or by delivery in person to the parties at the following addresser
If to University Care Plus: If to Physician:
University Care Plus P.O. Box 20627 Houston, Texas 772254k327 Arm: President J. Fntira AgrnnenL This Agreement embodies the entire Agreement between University Cam Plus and Physician and there are no agreements, representations, or warranties, oral or written, between University Care Plus and Physician other than those set forth in this Agreement.
• K. Wttc units' 11th AgrPemt This Agreenteg shall bind lad inure to the benefit of the parties here*. Nothing contained in this Agreement is intended to confer upon any person other than Physician and University Care Plus, any rights, remedies; obligations or liabilities wider or by mason of this Agreement.
L Aecatt$nnkc nntRecnrdc if Uth Agreement is determined to be subject to the provisions of Section 952 of F-L 96499, or its equivalent, which governs access to books and records of subeontactors of services to Medicaxe providers when the cost or value of such services under tSttxaa nes'dc $10,000 over a 12-month period, University Care Plus agrees to permit representatives of the Secretary of the Department of leaftj and EiSa Services and the Comptroller General, in accordance with criteria and procedures contained in applicable federal regulations, to have access to its books, documents and records as necessary to verify the cost of services provided under this Agreement.
I have read and understand this Physician Participation Acknowledgement and the Bylaws of University Care Phis as well as the Attachments listed below, and hereby acknowledge that I am bound by the conditions of participation in University Care Plus.
1052 AaachmentA PEE SCHEDULE
W.X7dD4L6&.1I7M$
1053 Atthdiment 1% PHYSICIAN PARTICIPATION CRITERIA
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1054 Attachment B PHYSICIAN PARTICIPATION CRITERIA
F - eavnsm CARE PLUS PARTLCIPA'IION cRFFEIUAT
university Cart Plus' Board of Directors rBoard") has the sole discretion with respect to the athbility of each applicant's credentials for purposes of initial and continued participation in University Care Plus. To be accepted for jBrt!cipadon and to maintain participation in University Care Plus, evay applicant must demonstrate that he or she fulfills all of the following criteria (unless specifically waived by the Board) and advise University Care Plus of any changes in any of the requested information within thirty (30) days of occurrence:
I. PK0FESSI0Z4ALcRUUU.
I. Graduation from a school of medicine, osteopathy or dentistry, which is:
• Accredited by the Liaison Committee on Medical Education and listed in the AAMC Directory of American Medical Education: or American Osteopathic Educado • Listed in the World Directory of Medical, Osteopathy or Dental Schools; or
• Appropriately recognized or accredited according to allied health professional
2. Valid, cnrrva professional licetsure for the State of Tens.
3. ValId, qinit Drug Enibroement Administration (DA) registration and Stare Narcotics License; OR, evidence that the applicant does not require flEA registration in order to deliver — ca
4. cant pttc&ial liability insurance coverage in the arnowit of $500,000 per occurrence and $1,500,000 allmpm for one (1) yr or in such - aniounL;required by University Care Pius with a artier tint is acceptable to University Care Plus. Individual exceptions tots maybe granted by the University Care Plus Board.
F.
6. Maintenance of a ISe! of clinical activity at a hospital specified by the Board sufficient to allow University Care Plus to objectively measure the cost, utilization and quality of services provided to enrolled patients. 7. Board certification (or eligibility) in a specialty recognized by the American Board of Medical Specialties or its international equivalent or the Amcrican Osteopathic
D3GGLfl4 278194
1055 Association. Exceptions to this may be granted by the Board upon naluation of training and experience. Applicants who have recently completed training and are board eligible may be considered for probationary membership pending board certitiäalion. Any applicant who is cetlifled by a board that requires recertification but fails to be recertified shall be automatically terminated as a Participating Provider. Physicians will accept patients only to that portion of their practice in which they are board certified.
& Willingness to accept patients under each contact negotiated by University Care Plus.
9. Willingness to pay, in a timely maimer, such dues and assessments as may be imposed from time to time by University Care Plus.
10. WWingnes to work cooperatively with other physicians, health professionals, the staff of University Care Plus in order to pcit the functions, duties, and obligations required by payor contacts, University Care Plus Bylaws, and the Physician Participation Agreement
11. Attendance at a minimum of one educational program per year spoisoied or endorsed by University Cam Plus.
12. Proof of annual participation in appropriate specialty continuing medical education.
13. Jnformaticn concerning involvement in OR sasisfactory resolution of the following:
a. Involvement in a professional liability suit, arbitration or settlement or any legal or t'egulatoq action in connection with the applicant's pmtessionai pncticc.
b. Denial or cancellation of professional liability insurance.
C. kecagniSg the requirements of the Americans. with Disabilities Act, current physical or nal health pxthlems which may interkre with the ability to practice medicine.
4. ProfessionaL disciplinary action by any stare or local meL society, specialty society, or state beard of medical omminers.
e. Sanczicms Of MY thid by the flEA, any stare drug agency, or any person or entity for improper prescribing procedures or actions.
L rnvoluniazy Suction, Ent,&1, suspension, or termination of hospital privileges, employment, or physician services contract, or imposition of proctorship or probation by any hospital at which qTfimt has had mcdi1 staff ptivUegcs.
g. Quality sanctions by a Professional Review Organization (PRO).
2 - 1056 h. Restricons (torn riving payments fttm Medicare, Medicaid, Or any other third party reimbursement proxams.
1. Any felony criminal charges brought against the physician applicant.
14. Provide his or her personal profile from the NationalPractitioner Data Bank, airrent within six (6) months or provide satisfactory explanation of rnediafly-r&ated lawsuits, claims and settlements.
15. Maintain a practice consistent with the goals of University Care plus and scrupulously observe the highest professional ethics.
16. Accurate and tzuthM completion of an Application and the appropriate release directing any and all çttfr1 that may have infin2alion with xpect to applicant's ability to practice medicine to provide such infennatica to University Can Plus and its agents on request
it Execution and agreement to abide by the terms of the University Care Plus Physician Participation Agroenient.
I!-
University Cam Plus shall evaluate statistics on a sufficient number of applicant's patient contacts at University Care Plus participadng hospitals to evaluate the cost effectiveness of applSnt's utilization of hhh care raources. This requirement may be wait or amended for applicants whose practices mrely require hospitalization of patients. Evaluation may include, without limimfinn:
a.. Pzequencyofservice b4 Intensity ofsnvice g. Average cad dDRG; d- Avenge cost per office encounter, C. Usage of ancillary senices I. Applicant's charge patterns; and g. wiThngnSs to participate in, accept the results of, and comply with the requftemaus of the inilinti,r management and quality improvement programs of tTniversity Care Plus and Its ecntrnd payors.
A significant deviation by applicant in the&ctcrs evaluated may indicate a practice style and philosophy incompatible with the business objectives Of University Care Plus. University Case Plus may determine, in its We discretion, to decline to execute a Participating Physician Agreement or terminate an existing Participating Physician Agreement based upon this information.
mrataos. tins,, 1057 AThThhThPnI r ANTiTRUST POLICY
1058 ANJIFRtJfl POLICY -
ANTITRUST POLICY AND PROCEDURE OF
A. To ftdilitate managed care contracting by:
1. Offering flyers an advantage by providing a past of physicians for participation in that managed case plans without the need for cumbersome, costly negotiations and other athninistntivc costs with each individual provider.
2. Offering Payots a new product—a group of qualified paththpating physicians from a wide variety of specialties who have agreed to participate in. UR, QA and credendaling programs established or adopted by the University Cue Plus (Corporaflcn').
B. Payers are still free to negodate and contact with individual physicians.
IL Services of the Corporation: A. In facilitating participation in managed care plans, the Corporation wITh I. Provide information to Payors regarding panicfpafingphysiciaós' fees, which may include the usual and customary fees and the fees at which they have individuafly et.'A thSr gezvnl willingness to participate In managed r plans; 2. Maintain confidentiality of fee information by ivhlbiqg an independent non- physician consultant or employee who will not sham fee b rmatio'a with competing physicians
3. Report to Payor the non-price terms under whichparticipating physicians have individually indicated they are generally willing to participate in. managed care plans
4. Allow any Payer to approach participating physicians directly, and allow participating physicians to negotiate with Payors, subject to any employment constraints imposed on those physicians by .th* faculty or othet employee S S* Encourage contractual relationships between Payers and participating physicians to provide covered services on terms acceptable to the Payor and participating Physicians- B. In any circumstances, the Corporation with
I- Not promote, tate or participate in collective decisions by competing physicians to participate in or refuse Payer's fee.fa-seMcs plans;
2. HS dictate terms (price or otherwise) on which participating physicians will participate in Payor's feefor-scvia plans; and.
3. Jt share information among competing physicians as to terms (1xr1cc or otherwise) on which they will coafract or do business with any Pay& sfee-for- arñceplasr, other than disclosing the terms agreed to with a. particular Payor in the course of negotiations as described above.
YL!W31J41412751*2
1059 2. Each applicant tall be evaluated to determine if his or her participation enhances University Care Plus' ability to fulfill its business needs. The evaluation shall include, without limitation:
a. Applicant's specially; 1,. The need for a physician in a specific geographic area C. The number of physicians necessary to service the population; 4. The relaticm ship of an applicant to other Participating Physicians ,, and e. Unique skills or characteristics such as foreign language proficiency or a fen2le physician offering obstetrical or gynecological services when patient or payor deniands indicate unmet needs for such physicians.
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1060 • kttaehwit U GRIEVANCE POLICY
UMVERSITY CARE PLUS • POLIC'! Mi! PROCEDURE FOR GRiEVANCES AND
ApvcAis OF ADVERSE DETERMINATIONS l'ttituis of this pmcthzre Is to offer a fair opportunity to any Pardoipating Physician of University On Plus (the 'Co poaioa') to S relajal grievances or complaints or to appeal a decision by Corporation to troinare his or her patticipalian in the Corporation. j, Apj1inbUty. Wbeaeve
a. A Partleipoting Physician has a grievance or complaint reug the Operation oft Corporation, or
b. The Board has under corWderefluji a recommendation by the Participation Committee ott method trecommendation to tern*iztate or sanction the participation of Physician Patticipathn for at or more of the specific zea'j set out in the polieJes and pmceduzts of Corporation,
the Board may off& the affect Participating Physician the opportunity to disms the matter prior to final action. The Corporation Board may, suspertd petttpnnon pending the outcome of the xcvww and appabpra
2. W.4ttvsn R.qn.t pa**a&g Physid mus Mfta a wrifli nqutst to appeal a recoaimeadation to torminnt. ptffcipasicn to the Boad in writing within fartyflve (45) days of receiving notitibi dthe adverse deciSs Paihne to submit such request during this period will zJth waiver of any right to appeal. PsrbthpaSg Physicians who wish to air grievrinces or complaints mug also submit a Written request for renew to the Board.: • 3, Rs'iew P,,o.i The review panel, comprised of either the E.ucnt.ve Committee or a special commifte appointed by the Board at its dscreaion, will disainthc mater with the Participating Physidan and report its flndhigsto the entire Board.
L The review, whether for purposes of airing grievancesInd complaints or reviewing adverse membership deserminatioris, is intended to S the Participating Phyician an oççortuity to address any srciai cilcumsthrces that may apply, and to respond to questions and resolve any outstanding issues the review pand may have,
1O5 2Th1*2
b. Because neither a review of a Participating Physician's grievance or complaint regarding the Corpontion's operation nor the decision by Corporation to tcrmMate the Paitpadng Physicia&s pttigifltin in the Corporation will affect faculty status at University of Texas - Houston Ecaith Science Center or the Pardcipatiug Physician's privileges at any çartidpafing hospital or be reportable as a peer review action, the conduct of the tbe informal innana 1061 4: Fee Schedule(s) (indicate type(s) of Fee Schedule(s) attached hereto) X Discounted Fee-for-service -AND/OR- JL Capitated Physician Participation Crittha Antitrust Policy Qxievajwe Policy
(&gaaturc) f+o,4A1tT N) pXt (-9)1,IflS$ 3 -24 'f3 I 5nnni , tjjstc, TX 77 (Mdius) 713-742-360 (TeIepbeo Number)
ACKNOWLEDGED AND ACCEPTED THIS Ir DAY GF F'' ,1996:
UNIVERSITY C t .
President
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