5th Circuit Rules Against Emergency Physicians Seeking Private Cause of Action under Texas Emergency Care Statutes

In Texas, hospital employees may not deny emergency care to a patient based upon ability to pay.  The Texas Emergency Care Statutes (Tex. Ins. Code 1271.155(a), 1301.0053(a) and 1301.155(b)) require health insurers to reimburse ER physicians at the “usual and customary rate” if emergency care is provided to an insured patient, but the physicians are not within the provider network for the insurer.  A group of emergency doctors that are out-of-network for UnitedHealthcare (“UHC”) filed suit against UHC for failure to reimburse them at the “usual and customary rate” under the Emergency Care Statutes.  UHC argued that the statutes did not provide a private cause of action that would allow the physicians to sue.  The trial court disagreed, finding that a private cause of action was created, and also finding that the doctors’ claims were not preempted by ERISA.

UHC appealed; the 5th Circuit certified the question to the Texas Supreme Court of whether or not the doctors had a private cause of action.  The Texas Supreme Court ruled that no private cause of action was created under the statutes.  Therefore, the 5th circuit reversed the trial court, remanding for dismissal of the claims.  Because there was no private cause of action, the appellate court did not address the preemption issue.  ASC Primary Care Physicians Southwest, P.A., et al. v. UnitedHealthcare Ins. Co., et al., No 21-20168, 5th Cir. Feb. 16, 2023.