# Texas Workers' Compensation Commission v. Patient Advocates of Texas

> Texas Supreme Court · May 28, 2004 · 47 Tex. Sup. Ct. J. 607

URL: https://www.frixlaw.com/law-library/cases/9512835

## Case

- **Full name:** TEXAS WORKERS’ COMPENSATION COMMISSION, Petitioner, v. PATIENT ADVOCATES OF TEXAS and Allen J. Meril, M.D., Respondents
- **Court:** Texas Supreme Court
- **Decided:** May 28, 2004
- **Citations:** 47 Tex. Sup. Ct. J. 607; 136 S.W.3d 643; 2004 Tex. LEXIS 477; 2004 WL 1194131
- **Precedential status:** Published
- **Opinion:** Concurrence by Smith
- **Judges:** Wainwright, Phillips, Hecht, Owen, O'Neill, Jefferson, Schneider, Smith, Brister
- **Cited by:** 486 later opinions in the Frix Law Library

## Citator (automated)

- No negative treatment found by the automated citator. That is not the same as a confirmation that the case is good law; read the citing cases.
- Full citator and citing cases: https://www.frixlaw.com/law-library/cases/9512835

## How later opinions describe it (automated extraction)

- noting that under Medical Fee Guideline 1996 promulgated by the Division, any party not satisfied with the Division’s decision on proper payment of claim "may continue the review process through [the State Office of Administrative Hearings] and then the courts"
- holding no due-process violation when there was “no evidence presented to show that [agency] rules . . . prevent[ed] [a party] from taking advantage of these defined procedures to challenge the reimbursement amounts paid for medical services.”
- describing former Rule 133.304(m) in only these terms: “A health care provider that disagrees with a carrier’s determination of the reimbursement amount may initiate the dispute resolution process.”
- explaining that substantive due process protects against the arbitrary and oppressive exercise of government power

## Opinion text

Justice SMITH,
concurring.
The Court concludes that “a private insurance carrier’s act of reviewing medical bills and determining a reimbursement amount when no MAR has been established [does not fall] within the legal definition of a delegation.” 136 S.W.3d at 657. I agree but write separately to express my understanding that the carrier’s reimbursement determination does not constitute an administrative rule and that a de novo determination of the “fair and reasonable” reimbursement rate 1 will be made in both the TWCC medical service review 2 and the SOAH contested-case hearing 3 without deference to the carrier’s previous reimbursement determination.
.See 28 Tex. Admin. Code § 134.1 (c) (2004)("Reimbursement for services not identified in an established fee guideline shall be reimbursed at fair and reasonable rates as described in the Texas Workers’ Compensation Act, § 413.011 until such period that specific fee guidelines are established by the commission.”).
. See generally Tex. Lab.Code § 413.031.
. See Tex. Lab.Code § 413.031(k).

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Source: Frix Law Library, https://www.frixlaw.com/law-library/cases/9512835. Public record. Not legal advice.