Take the Fifth

Designated for publication

• Angelina Emergency Medical Associates PA v. Blue Cross and Blue Shield of Alabama, 24-10306, appeal from N.D. Tex.
  • Higginson, J. (Smith, Higginson, Douglas), breach of contract
  • Affirming summary judgment in favor of health insurers on claims by healthcare providers where no written assignment of the insured’s claims was provided, but reversing summary judgment on claims where a written assignment was provided, and remanding for further proceedings.
  • The case involves fifty-six Texas emergency-medicine physician groups (Plaintiffs-Appellants) suing twenty-four Blue Cross Blue Shield-affiliated plans (Blue Plans) from outside Texas, alleging underpayment of claims for reimbursement. The physician groups, who were out-of-network with the Blue Plans, claimed they were owed payments based on patients’ assignments of benefits to them prior to treatment. The district court granted summary judgment on all claims, citing issues with the assignment forms and language of the relevant plans.
  • The physician groups are facility-based providers contracted with hospitals to staff emergency departments. They treat emergency patients covered by the Blue Plans, often without knowing if the hospital is in-network or if the insurance will fully cover the treatment. As a standard practice, patients assign their insurance benefits to the physicians during registration, allowing the physician groups to pursue reimbursement from the insurers. Under the Affordable Care Act (ACA), insurers must pay out-of-network emergency service providers at least the greatest of three potential rates, though the case did not challenge compliance with the ACA’s “greatest-of-three” rule.
  • After the initial claims were partially paid, the physician groups pursued appeals under the Blue Plans’ appeals process, but often received generic responses or no reply at all. The physician groups then filed a lawsuit in 2018, alleging that Blue Cross Blue Shield of Texas (BCBSTX) and the Blue Plans underpaid the claims. Over 75% of the claims were dismissed after a settlement with BCBSTX, and the district court ruled on a smaller set of bellwether claims. The district court granted summary judgment on most of these claims, finding issues such as missing written assignments, failure to exhaust administrative remedies, and violations of the plans’ anti-assignment provisions.
  • The court identified four main issues with the assignments: (1) some assignments were made to hospitals rather than directly to the physician groups, (2) some assignments did not provide the right to sue, (3) some assignments were not produced in evidence, and (4) some Blue Plans had anti-assignment clauses that prohibited the physician groups from pursuing claims. The physician groups argued that these clauses should be ignored due to estoppel, as they were not aware of the clauses until after submitting claims. They claimed the Blue Plans’ actions, including partial payments and refusal to provide plan documents, prevented them from knowing about the anti-assignment clauses.
  • The district court also concluded that the physician groups had not exhausted administrative remedies, an essential step before filing lawsuits under ERISA. The physician groups argued they had followed the correct appeals process available to them, but the Blue Plans insisted that the physician groups should have followed the member appeals process. The court agreed with the Blue Plans, ruling that the physician groups did not exhaust the proper procedures. However, the appellate court found there was a factual dispute as to whether the physician groups could have known about the member appeals process, as they had requested the underlying plan documents from the Blue Plans. The court therefore remanded the case for further examination of these issues.

• U.S. v. Baxter, 24-50051, appeal from W.D. Tex.
  • Smith, J. (King, Smith, Douglas), criminal, sentencing
  • Vacating a condition of the supervised release portion of sentence that did not conform to the orally pronounced sentence, and remanding for entry of new written judgment.
  • Lloyd Baxter appealed his sentence for possessing an unregistered destructive device, arguing that the written judgment imposed certain conditions of supervised release (SR) that were not orally pronounced by the district court. While the court affirmed Baxter’s sentence in substantial part, it vacated one of the SR conditions and remanded for the written judgment to align with the oral pronouncement. The district court initially sentenced Baxter to five years of probation, with additional conditions including restrictions on controlled substances, psychoactive substances, substance abuse treatment, and submission to searches. After a violation of the probation conditions, the court revoked probation and imposed a 30-month prison sentence followed by three years of SR. However, Baxter argued that the written judgment included conditions not orally pronounced.
  • The Fifth Circuit reviewed whether discrepancies between the oral pronouncement and written judgment created a conflict. It found that conditions regarding controlled substances, psychoactive substances, and inpatient drug treatment did not conflict with the oral pronouncement, as they aligned with mandatory or previously stated conditions. However, the written judgment’s inclusion of a search condition was found to broaden the SR conditions beyond the oral pronouncement, leading to its vacatur. The court affirmed the sentence except for the submission-to-search condition, remanding the case for the written judgment to be amended to reflect the oral pronouncement accurately.

Unpublished decisions

• U.S. v. Cash, 24-10243, appeal from N.D. Tex.
  • per curiam (Stewart, Clement, Wilson), criminal
  • Affirming conviction of possession with intent to distribute cocaine and heroin.

• U.S. v. Waddell, 24-10814, appeal from N.D. Tex.
  • per curiam (Davis, Smith, Higginson), criminal
  • Affirming conviction of conspiracy to distribute and to possess with intent to distribute fentanyl.

• U.S. v. Amill, 24-11101, appeal from N.D. Tex.
  • per curiam (King, Haynes, Ho), criminal
  • Granting Anders motion to withdraw, and dismissing appeal.

• RokIt Drinks, L.L.C. v. Landry’s Inc., 23-20506, appeal from S.D. Tex.
  • per curiam (Dennis, Southwick, Engelhardt), breach of contract
  • Affirming summary judgment for defendant restaurant group on breach of contract and other claims by supplier of drink products.

• U.S. v. Alaniz, 24-40236, appeal from S.D. Tex.
  • per curiam (Jones, Graves, Rodriguez, by designation), criminal
  • Affirming conviction of possession of a firearm and ammunition by a felon.

• Wingfield v. Adekoya, 24-40663, appeal from E.D. Tex.
  • per curiam (Barksdale, Stewart, Ramirez), prisoner suit
  • Affirming dismissal of Texas state prisoner’s deliberate indifference and ADA claims.

• U.S. v. Galaviz, 24-50282, appeal from W.D. Tex.
  • per curiam (Jones, Graves, Rodriguez, by designation), criminal
  • Affirming conviction of conspiring to possess with intent to distribute a controlled substance and possessing with intent to distribute a controlled substance.

• Wood v. North Mississippi Medical Center, Inc., 24-60546, appeal from N.D. Miss.
  • per curiam (Stewart, Clement, Wilson), breach of contract
  • Affirming summary judgment dismissal of plaintiffs’ claims against healthcare providers for unlawful billing practices.