Christus Health Gulf Coast v. Aetna, Inc. and Aetna Health, Inc.

Summary

The Supreme Court of Texas held that the Texas Prompt Pay Statute requires contractual privity between a health maintenance organization and a provider. Because the hospitals contracted with a delegated network rather than directly with Aetna, they could not pursue prompt-pay penalties against Aetna for unpaid claims. The court affirmed the court of appeals’ judgment and concluded that any administrative remedy involving the delegated network was for the Insurance Commissioner, not a private provider action.

Holdings

1. The Texas Prompt Pay Statute requires contractual privity between the HMO and the physician or provider; an HMO is subject to the statute's 45-day payment obligation only when it has directly contracted with the provider.
2. Aetna's contractual or regulatory responsibilities concerning its delegated network did not expand its liability under the Prompt Pay Statute, and the 2001 amendment authorizes administrative intervention by the Insurance Commissioner rather than a private provider action against an HMO.

Questions Presented

1. Whether the Texas Prompt Pay Statute requires a direct contractual relationship between an HMO and a physician or provider before the statute's 45-day payment deadline and penalties apply.
2. Whether Aetna's responsibility for delegated-network functions, monitoring of the delegated entities, continued payment of some claims, or the statutory delegated-network provisions created Prompt Pay Statute liability despite the absence of direct contracts with the Hospitals.
3. Whether the 2001 amendment authorizing the Insurance Commissioner to require an HMO to reassume delegated claims-payment functions created a private cause of action against an HMO.

Disposition

affirmed