Edwards v. Blue Cross Blue Shield of Texas (Tex.App.- Dallas, Dec. 19, 2009, pet. denied)
(federal preemption) (federal preemption, Medicare reimbursement dispute brought under state law
theories, summary judgment on the pleadings without evidence) ("We conclude Edwards's pleadings
affirmatively show his state law claims are “inextricably intertwined” with Medicare benefits
determinations, and are preempted by the Medicare Act.")
09-0209
DRALVES GENE EDWARDS, M.D. v. BLUE CROSS BLUE SHIELD OF TEXAS, A DIVISION OF HEALTH
CARE SERVICE CORP.; from Dallas County; 5th district (05-07-01281-CV, ___ SW3d ___, 12-19-08)
We conclude Edwards's pleading and the record establish his claims are
preempted as a matter of law and this impediment to his suit cannot be corrected
by amending his pleadings.   See Footnote 14  Because this ground is sufficient
to support the trial court's summary judgment, we need not address the
remaining sub-issues
File: 071281F - From documents transmitted: 12/22/2008
AFFIRMED; Opinion Filed December 19, 2008.
S
In The
Court of Appeals
Fifth District of Texas at Dallas
............................
No. 05-07-01281-CV
............................
DRALVES GENE EDWARDS, Appellant
V.
BLUE CROSS BLUE SHIELD OF TEXAS,
A DIVISION OF HEALTH CARE SERVICE CORP., Appellee
.............................................................
On Appeal from the 44th Judicial District Court
Dallas County, Texas
Trial Court Cause No. 03-06872-B
.............................................................
OPINION

Before Justices Moseley, Richter, and Francis

Opinion By Justice Moseley

 Appellant, Dralves Gene Edwards, M.D., sued appellee Blue Cross Blue Shield of Texas (Blue
Cross), alleging he was a Medicare provider and that Blue Cross, a Medicare Part B carrier, had
wrongfully denied almost all of his Medicare claims in 1997 and 1998. Dr. Edwards did not seek
recovery for the Medicare claims themselves, which he pursued (mostly with success) through the
Medicare administrative review process, but sought recovery for consequential damages based on a
variety of state law causes of action.

 The trial court granted summary judgment in favor of Blue Cross, and Edwards appealed. For the
reasons discussed below, we conclude Edwards's pleadings affirmatively show his state law claims are
“inextricably intertwined” with Medicare benefits determinations, and are preempted by the Medicare
Act. Thus, we affirm the trial court's judgment.
Background

 The Medicare Act, 42 U.S.C. §§ 1395-1395iii, is a federally subsidized health insurance program for
elderly and disabled persons consisting of several parts. See Marsaw v. Trailblazer Health Enters., L.L.
C., 192 F.Supp.2d 737, 740 n.2 (S.D. Tex. 2002). The Act is administered by the Secretary of the
Department of Health and Human Services (HHS), through the Center for Medicare and Medicaid
Services (CMS). See RenCare, Ltd. v. Humana Health Plan of Tex., Inc., 395 F.3d 555, 556 (5th Cir.
2004). CMS contracts with private insurance companies (like Blue Cross) to administer Medicare
benefits. Marsaw, 192 F.Supp.2d at 740.   See Footnote 1  Under Parts A and B of Medicare, these
private contractors process claims for reimbursement from health care providers and determine
whether the expenses are covered by Medicare and whether the services were reasonable and
medically necessary. Id. If approved, funds are taken from the Federal Supplementary Medical
Insurance Trust Fund and paid by the intermediary or carrier directly to the providers for each
qualifying service provided to a beneficiary. RenCare, 395 F.3d at 558.   See Footnote 2

 Edwards sued Blue Cross on June 30, 2003 for state law breach of contract and tort claims relating to
Blue Cross's denial of nearly all of his Medicare Part B reimbursement claims over a two- year period.
He later amended his petition to sue Trailblazer Health Enterprises, L.L.C. Trailblazer removed the
case to federal court alleging it acted as a fiscal agent of the Secretary of HHS and removal was
proper under 28 U.S.C. § 1442(a)(1), allowing removal by an “officer of the U.S. or any agency
thereof, or persons acting under that officer” where the defendant was “acting under color of such
office.” Edwards then dismissed Trailblazer from the suit and filed a motion to remand. The federal
court granted the motion to remand after it concluded Blue Cross did not timely remove the suit to
federal court and failed to establish another basis for federal jurisdiction.

 The facts are taken from Edwards's live pleading, his sixth amended petition filed a month after he
filed his response to Blue Cross's motion for summary judgment.   See Footnote 3  Edwards alleged he
was a provider of Medicare services and Blue Cross was the Medicare Part B carrier obligated to
reimburse him for medical services he provided to Medicare beneficiaries. Edwards alleged that Blue
Cross, in connection with negotiations for its acquisition by Health Care Service Corporation, adopted
a program that “targeted doctors who were the largest billers to the Medicare systems in a given area
in order to systematically eliminate these physicians from the system.” The purpose of this program
was to improve Blue Cross's standing with the federal government because Blue Cross was “in danger
of losing [its] contract with the government regarding [its] Medicare services in Texas.” On August 26,
1997, Edwards was notified that he was being placed on 100% pre-payment review for his Medicare
billings. He alleged Blue Cross “negligently” administered the pre-payment review and “fraudulently”
denied almost 100% of his Medicare billings over a two-year time frame, forcing him to close his
medical practice. Edwards claims he is seeking damages he sustained as a result of the breach of
contract and torts he alleges and not under “any derivative claim based upon any assignment of
patient benefits.”

 Edwards alleged he was a third-party beneficiary of Blue Cross's contract with CMS and Blue Cross
breached that contract not by placing him on pre-payment review, but by failing to actually review all of
his claims and investigate the validity of the services rendered after placing him on pre-payment
review. He alleged Blue Cross was “not only liable for the money owed to [him] for the
individual bills, but for the foreseeable consequences of their actions.”

 Blue Cross filed a motion for summary judgment under rule 166a(b), but did not attach any summary
judgment evidence.   See Footnote 4  Tex. R. Civ. P. 166a(b). The motion raised four grounds for
summary judgment: (1) lack of subject matter jurisdiction because Edwards's claims arise under the
Medicare Act and must be pursued in the administrative process and federal court; (2) sovereign
immunity based on Blue Cross's performance of official functions of the Secretary under its contract as
a Medicare carrier; (3) the statute of limitations barred the state law claims and the statute was not
tolled while Edwards sought administrative review of the denial of Medicare benefits; and (4) Edwards's
state law claims were preempted by the Medicare Act and his only remedy is the administrative review
of benefit determinations and federal judicial review of adverse decisions of the Secretary. After
extensive briefing, pleading amendments, and motions relating to the motion for summary judgment,
the trial court conducted a hearing and signed an order granting the motion for summary judgment
without specifying the grounds therefor.

 Edwards appeals and brings one issue (with seven sub-issues) arguing the trial court erred in
granting summary judgment. See Malooly Bros., Inc. v. Napier, 461 S.W.2d 119, 121 (Tex. 1970). The
first three sub-issues argue Blue Cross's motion was insufficient to prove any of its defenses because
it failed to introduce evidence; a no-evidence motion cannot be used by a defendant to prove
affirmative defenses; and the summary judgment can be reviewed only on Edwards's pleadings and
evidence. The last four sub-issues argue the trial court had jurisdiction and Blue Cross failed to
conclusively prove each of the affirmative defenses of preemption, sovereign immunity, and statute of
limitations.

Standard of Review

 We apply well-established standards of review to summary judgments. See Nixon v. Mr. Property
Management Co., 690 S.W.2d 546, 548-49 (Tex. 1985) (summary judgment standards of review); see
also King Ranch, Inc. v. Chapman, 118 S.W.3d 742, 750-51 (Tex. 2003) (no-evidence summary
judgment standards of review).

 Edwards argues Blue Cross's motion for summary judgment was insufficient because it failed to
attach summary judgment evidence. A defendant may “move with or without supporting affidavits for a
summary judgment in his favor as to all or any part” of a claim against him. Tex. R. Civ. P. 166a(b). A
party may also move for traditional summary judgment based on the pleadings and judicial admissions
of the opposing party. See Swilley v. Hughes, 488 S.W.2d 64, 67 (Tex. 1972); Washington v. City of
Houston, 874 S.W.2d 791, 794 (Tex. App.-Texarkana 1994, no writ) (“where the plaintiff's pleadings
themselves establish the lack of a valid cause of action, such as the fact that the statute of limitations
has run, or if the pleadings allege facts that, if proved, establish governmental immunity, pleadings
alone can justify summary judgment and special exceptions are not required”). Pleadings may be used
as summary judgment evidence when they contain statements rising to the level of admitting a fact or
conclusion which is directly adverse to that party's theory or defense of recovery. Judwin Props., Inc. v.
Griggs and Harrison, 911 S.W.2d 498, 504 (Tex. App.-Houston [1st Dist.] 1995, no writ).

 Edwards also argues Blue Cross's motion fails as a no-evidence motion for summary judgment
because it seeks to establish Blue Cross's own affirmative defenses. To this extent, we agree. A no-
evidence motion for summary judgment must attack a specific element of the opposing party's cause of
action or defense; it cannot be used to establish the movant's own cause of action or defense. See
Tex. R. Civ. P. 166a(i) (party may move for no-evidence summary judgment on “one or more essential
elements of a claim or defense on which an adverse party would have the burden of proof at trial”)
(emphasis added); De la Garza v. De la Garza, 185 S.W.3d 924, 927 (Tex. App.-Dallas 2006, no pet.).
We also agree with Edwards that Blue Cross's motion for summary judgment should be reviewed
based on his pleadings and the evidence he presented in response to the motion.
 We will consider Blue Cross's motion as a motion for summary judgment on Edwards's pleadings. We
assume the allegations of fact in Edwards's pleadings are true and indulge all inferences from the
pleadings in his favor. See Natividad v. Alexsis, Inc., 875 S.W.2d 695, 699 (Tex. 1994). Summary
judgment may be proper if the allegations in the pleading affirmatively show the claims are barred as a
matter of law and the defects cannot be cured by amendment. See In re B.I.V., 870 S.W.2d 12, 13
(Tex. 1994).

Discussion

A. Jurisdiction

 We discuss the jurisdiction issue first. Blue Cross asserted in its motion for summary judgment that
the Medicare Act deprived the trial court of jurisdiction to hear Edward's state law claims because the
state law claims were inextricably intertwined with a claim for Medicare benefits and therefore they
arose under the Medicare Act. See Heckler v. Ringer, 466 U.S. 602, 615 (1984). Edwards counters
that his claims are state law statutory, tort, and contract claims not for the Medicare benefits
themselves-he has sought those through administrative appeal under Medicare-but for foreseeable
consequential damages arising from Blue Cross's allegedly wrongful denial of the original claims. He
argues these state law claims are within the jurisdiction of a Texas district court.
 A Texas district court is a court of general jurisdiction and is presumed to have subject matter
jurisdiction unless a showing is made to the contrary. Dubai Petroleum Co. v. Kazi, 12 S.W.3d 71, 75
(“all claims are presumed to fall within the jurisdiction of the district court unless the Legislature or
Congress has provided that they must be heard elsewhere”). Federal district courts are courts of
limited jurisdiction and subject matter jurisdiction is never presumed. Id.

 The Texas supreme court has stated that

[f]ederal preemption “is ordinarily a federal defense to the plaintiff's suit” but does not ordinarily
deprive a state court of jurisdiction. Metro. Life Ins. Co. v. Taylor, 481 U.S. 58, 63, 107 S.Ct. 1542, 95
L.Ed.2d 55 (1987). As a result, “[t]here are thus some cases in which a state law cause of action is
preempted, but only a state court has jurisdiction to so rule.” Romney v. Lin, 105 F.3d 806, 813 (2d
Cir. 1997) (denying rehearing). Consequently, we disagree with the court of appeals' conclusion that
federal preemption, without more, would necessarily deprive the trial court of jurisdiction.

Mills v. Warner Lambert Co., 157 S.W.3d 424, 427 (Tex. 2005) (per curiam). In keeping with this
analysis, we conclude the trial court had jurisdiction to determine the claims alleged by Edwards and
whether those claims were preempted by the Medicare Act. We now review the other grounds for
summary judgment to determine if they support the trial court's judgment.

B. Other Grounds for Summary Judgment

 The laws of the United States are the “supreme Law of the Land”   See Footnote 5  and “[i]f a state
law conflicts with federal law, it is preempted and has no effect.” Great Dane Trailers, Inc. v. Estate of
Wells, 52 S.W.3d 737, 743 (Tex. 2001). State law may be preempted in three ways: (1) federal law
may expressly preempt state law; (2) federal law may impliedly preempt state law where a “statute's
scope indicates that Congress intended federal law or regulations to occupy the field exclusively”; or
(3) federal law may impliedly preempt state law where state law actually conflicts with federal law
because it is impossible for a private citizen to comply with both state and federal requirements or state
law obstructs accomplishing and executing Congress' full purposes and objectives. BIC Pen Corp. v.
Carter, 251 S.W.3d 500, 504 (Tex. 2008) (citations omitted).
 Under 42 U.S.C. § 405(h), made applicable to the Medicare Act by 42 U.S.C. § 1395ii, it is clear that
section 405(g) “is the sole avenue for judicial review of all 'claims arising under' the Medicare Act.”
Heckler, 466 U.S. at 615. Under 42 U.S.C. § 405(g), a final decision of the Secretary of HHS (issued
only after exhaustion of all administrative review) may be reviewed in federal district court. See
Marsaw, 192 F.Supp.2d at 744. A claim arises under the Medicare Act if it is “'inextricably intertwined'
with a Medicare benefits determination,” or if “'both the standing and the substantive basis for the
presentation' of the claim” is the Medicare Act. Kaiser v. Blue Cross of Cal., 347 F.3d 1107, 1112 (9th
Cir. 2003) (quoting Heckler, 466 U.S. at 614, 615). Because Edwards's claims are arguably based on
state law, we are concerned only with the first test-whether the claims are inextricably intertwined with a
Medicare benefits determination. Id.; see RenCare, 395 F.3d at 557.
 Several federal courts have addressed state law claims very similar to Edwards's and concluded
those claims were inextricably intertwined with claims for Medicare reimbursement, and thus arose
under the Medicare Act. In Bodimetric Health Services, Inc. v. Aetna Life & Casualty, 903 F.2d 480 (7th
Cir. 1990), Bodimetric alleged the Secretary released a contractor evaluation critical of Aetna's
performance as a Medicare carrier. In response, and in order to improve its contract performance
evaluation and retain its contract as a fiscal intermediary, Aetna began denying Bodimetric's
applications for reimbursement on a regular basis. See id. at 482-83. Bodimetric claimed this “arbitrary
campaign of denials” caused it to close its facilities and lose $8 million. Id. Bodimetric sued Aetna
seeking damages for fraud and other tort and contract causes of action. Id. Bodimetric alleged Aetna
denied “thousands of claims without regard to their underlying substance” and, like Edwards, asserted
“that administrative law judges [had] reversed almost all of Aetna's denials where Bodimetric [had]
entered an appearance and argued for reversal.” Id.   See Footnote 6  The court concluded all of
Bodimetric's claims arose under the Medicare Act, stating a “party cannot avoid the Medicare Act's
jurisdictional bar simply by styling its attack as a claim for collateral damages instead of a challenge to
the underlying denial of benefits.” Id. at 487.   See Footnote 7  The court acknowledged the
congressional intent behind the Medicare procedures:

 By enacting the exclusive review provisions of the Medicare Act, Congress expressly limited the
remedies that can be sought by dissatisfied claimants from fiscal intermediaries. While this may, in
some cases, foreclose avenues of relief generally available to civil litigants, it is also the system
Congress clearly intended to implement. Any decision to modify this aspect of the system must be
made by Congress, not by the courts.  Id. at 490.

 In Kaiser, a provider of home health services to Medicare beneficiaries, CHH, substantially reduced
the number of its patients and services it provided as a result of pending changes to the rules on
allowable costs of home health agencies. 347 F.3d at 1110. However, CHH continued to receive
interim payments at relatively high levels based on its prior patient volume. Id. As a result, it was
overpaid more than a million dollars. CHH sought an extended repayment plan from Blue Cross, but
Blue Cross denied the request and decided to withhold all Medicare payments until the overpayment
was recouped. Thereafter CHH closed its operations and filed bankruptcy. Id. The Kaisers, former
shareholders of CHH, obtained from the bankruptcy trustee an assignment of any CHH claims related
to Medicare. They then sued Blue Cross and the HCFA   See Footnote 8  under several state and
federal laws alleging Blue Cross's conduct forced CHH into bankruptcy, causing CHH's (now the
Kaisers') damages. Id. at 1111. The Kaisers argued their claims did not arise under Medicare because
they sought damages other than the Medicare payments and noted CHH was pursuing the claim for
Medicare payments through the administrative process apart from the Kaisers' claims. Id. at 1112 n.2.
The ninth circuit concluded “Bodimetric is perfectly applicable to the facts in this case” and the Kaisers'
claims were “inextricably intertwined” with CHH's claims for Medicare reimbursement. Id. at 1114-15
(“Hearing most of the Kaisers' claims would necessarily mean redeciding Blue Cross's CHH-related
Medicare decisions.”). Even though the Medicare administrative review process would not provide
them with the damages they sought, “administrative exhaustion of the Kaisers' claims would still serve
the purposes of exhaustion and not be futile in the context of the system.” Id. at 1115. The court
affirmed the district court's dismissal of the suit for failure to exhaust administrative remedies. Id.

In both Bodimetric and Kaiser, the plaintiffs had undertaken the administrative review process with
respect to their Medicare reimbursement claims, but had not entirely completed the process. Edwards
contends this is a critical distinction from his case because he has completed-and won-the vast
majority of the administrative reviews of Blue Cross's denials of his Medicare claims. Thus, despite the
obvious similarity between his claims and those in Bodimetric and Kaiser, Edwards claims he can now
sue in state court to recover consequential damages for delays in making those payments.
 
However, the Fifth Circuit Court of Appeals has concluded that even if an administrative review of the
Medicare reimbursement claims has been completed, state law claims based on the alleged wrongful
denial of those claims still “arise under” Medicare and thus were properly dismissed. Marsaw v.
Thompson, 133 Fed. Appx. 946, 949 (5th Cir. 2005) (not designated for publication). In that case,
Marsaw initially sued Trailblazer and the Secretary alleging racial discrimination and various tort and
breach of contract claims based on Trailblazer's placing of his clinics “in pre-payment review (which
forced the clinics to engage in lengthy administrative work to receive Medicare reimbursements) and
then denied reimbursements of the submitted claims, ultimately forcing Marsaw out of business.” Id. at
947.   See Footnote 9  Marsaw's initial suit was dismissed by the district court for his failure to exhaust
administrative remedies under the Medicare Act. See Marsaw, 192 F.Supp.2d at 737. He did not
appeal that decision. Marsaw, 133 Fed. Appx. at 947. Instead, after the administrative review of his
Medicare claims was completed and he received payment of 98 percent of the claims denied by
Trailblazer, Marsaw filed a second suit seeking an additional $50 million in damages from the
Secretary and Trailblazer for initially denying his claims. Marsaw, 133 Fed. Appx. at 947.
 The fifth circuit determined that

to fully address Marsaw's claim that his constitutional rights were violated through improper
enforcement of Medicare regulations, a court would necessarily have to review the propriety of
thousands of Trailblazer's Medicare claims determinations and the decisions of its hearing officers to
determine whether there was legitimate doubt about Marsaw's compliance.

Id. at 948. The “sole avenue” for judicial review of all claims arising under the Medicare Act is section
405(g) and a “condition for jurisdiction under § 405(g) is that the Medicare system has made a
determination adverse to the claimant.” Id.

 We conclude that the trial court would have to review each of Edwards's Medicare reimbursement
claims and Blue Cross's decisions to deny them in order to determine if there was a good faith or non-
tortious basis for Blue Cross's actions. Even though Edwards has now received an administrative
review, he wants to go further and recover amounts in addition to the benefits. To do so, he must
prove the original denial was not only incorrect, but was also tortious or a breach of a contractual or
statutory duty. However, Medicare only permits a judicial review after exhaustion of administrative
reviews and an adverse decision. Marsaw, 133 Fed. Appx. at 948. When the administrative review
results in payment or a favorable decision for the provider, the statute permits no further review. Id.
Thus we conclude that, like Marsaw's claims, Edwards's claims “arise under the Medicare Act (and are
not collateral to it) because they are 'inextricably intertwined' with plaintiffs' substantive claims for
entitlement under Medicare.” Id.

 Edwards filed a post-submission letter brief arguing Marsaw and similar cases are distinguishable
because the federal courts concluded only that federal jurisdiction was lacking and did not decide
whether state law claims remained for a state court to decide. We are not persuaded by his
arguments. While the federal court in Marsaw refused to exercise its discretionary supplemental
jurisdiction to address the state law claims,   See Footnote 10  the reasoning and analysis of the
court's opinion clearly indicates any state law claims were inextricably intertwined with Medicare and
thus preempted by the Medicare Act. See Marsaw, 133 Fed. Appx. at 948 (addressing Marsaw's claims
would require reviewing thousands of the carrier's Medicare claims determinations “to evaluate
whether there was legitimate doubt about Marsaw's compliance”).   See Footnote 11

 Edwards argues his claims do not arise under the Medicare act because he is not seeking to recover
Medicare benefits, but “foreseeable consequential damages he incurred when he was forced to close
his medical practice as a proximate result of Blue Cross' [sic] conduct in denying him any revenue for a
period of two years.” However, a suit seeking non-Medicare damages may still arise under the
Medicare Act. See Marin v. HEW, Health Care Fin. Agency, 769 F.2d 590, 592 (9th Cir. 1985) (noting
provider's suit for damages caused by negligent failure to process claims was “anticipated by the
statute” and provider's “demand for greater damages than the statue provides would render
meaningless the jurisdiction restriction of § 405(h)”). Bodimetric also recognized that congress has
limited the remedies available for dissatisfied providers. Bodimetric, 903 F.2d at 487 n.5 (observing
administrative process may not afford plaintiff all relief it sought pursuant to its state law claims, but
“Congress, through its establishment of a limited review process, has provided the remedies it deems
necessary to effectuate the Medicare claims process”). As the ninth circuit recognized, “The fact that
the Kaisers seek damages beyond the reimbursement payments available under Medicare does not
exclude the possibility that their case arises under Medicare. Simply put, the type of remedy sought is
not strongly probative of whether a claim falls under § 405(h).” Kaiser, 347 F.3d at 1112; see also
Marsaw, 133 Fed. Appx. at 948.

 Edwards argues not all state law tort claims relating to Medicare benefits are preempted by the
Medicare Act. See Ardary v. Aetna Health Plans of S. Cal., 98 F.3d 496 (9th Cir. 1996); Kelly v.
Advantage Health, Inc., 1999 WL 294796 (E.D. La. May 11, 1999) (not designated for publication).
Those and similar cases, however, are distinguishable as they involved claims by the Medicare
beneficiary or their representatives for wrongful death or damages for state law torts for delays in
granting the benefits.   See Footnote 12  These cases are not persuasive in light of other cases more
closely on point. Indeed, in Kaiser, a case very similar to Edwards's, the ninth circuit expressly limited
its holding in Ardary to patient tort claims. Kaiser, 347 F.3d at 114 (“the Ardary analysis convinces us
that its holding does not extend beyond patients and torts committed in the sale or provision of medical
services”).   See Footnote 13

 Like other courts, we are “persuaded by Bodimetric and subsequent cases holding that claims for
consequential damages resulting from adverse decisions by Medicare carriers are 'inextricably
intertwined' with claims for benefits.” Reg'l Med. Transp., Inc. v. Highmark, Inc., 541 F.Supp.2d 718,
729 (E.D. Pa. 2008). Edwards's claims are based on Blue Cross's alleged wrongdoing in the course of
reviewing and administering his Medicare reimbursement claims. Edwards alleges most of those
reimbursement claims have been paid after administrative review, but “[t]o the extent that plaintiffs
have obtained the relief sought in those proceedings, plaintiffs are limited to that recovery and cannot
obtain more than permitted by the Medicare program by couching their claims as state law challenges.”
Id. “[I]rrespective of what relief plaintiffs actually obtained in the administrative process, [42 U.S.C.] §
405(h) bars judicial review of plaintiffs' state law tort claims, all of which are 'inextricably intertwined'
with claims for Medicare benefits.” Id. Because Edwards has now exhausted his administrative
remedies and obtained “precisely the Medicare payments he claims were wrongfully denied, and the
statute entitles him to no other relief, his case is moot.” Marsaw, 133 Fed. Appx. at 948.

Conclusion

 We conclude Edwards's pleading and the record establish his claims are preempted as a matter of
law and this impediment to his suit cannot be corrected by amending his pleadings.   See Footnote 14  
Because this ground is sufficient to support the trial court's summary judgment, we need not address
the remaining sub-issues raised in Edwards's appeal. Tex. R. App. P. 47.1. We overrule Edwards's
sole issue on appeal.

 We affirm the trial court's judgment.

JIM MOSELEY

JUSTICE

071281F.P05        

Footnote 1         These private insurance companies are known as “fiscal intermediaries” under Part A
and Medicare “carriers” under Part B. 42 U.S.C. §§ 1395h, 1395u. Part A generally covers inpatient
medical services, while Part B covers most out-patient services such as doctor visits. See 42 U.S.C. §§
1395d-1395i-5; 1395k-1395w-4.

Footnote 2         Although this case involves Medicare Part B, it is important to distinguish Medicare
Part C programs. Part C provides a managed care option to Medicare enrollees and is administered by
private, managed health care organizations or HMOs. RenCare, 395 F.3d at 556. Part C differs from
Parts A and B in that it is based on a fixed monthly payment to Part C organizations for providing
medical care to Medicare patients. Id. 395 F.3d at 556-57. A Part C organization does not review
claims from medical providers to determine the amount of allowed reimbursement for medical services;
it “receives a fixed amount per month for each enrolled [Part C] patient regardless of the value of
services the patient actually receives.” Id. The organizations may freely enter into contracts with other
providers to provide services, but assume all risk of expenses for medical services and maintain
arrangements for insolvency. Id. at 558-59.