Texas NP Lawsuit 2026: Fight Against Physician Gatekeeper Fees

Most important takeaways…

Texas NPs filed a Sherman Act lawsuit on July 22, 2026.
Texas NPs pay physicians up to $5,000 monthly for delegation agreements.
A victory would eliminate mandatory physician gatekeeper fees for Texas NPs.

On July 22, 2026, nurse practitioner Sandy McCoy and the Texas Nurse Practitioners association sued state officials in Travis County over the state’s mandatory collaborative practice agreement law.¹ McCoy, with 30 years in practice, opened her own Plano clinic and immediately faced the requirement to contract with a physician gatekeeper.

The lawsuit pairs state constitutional claims with an unprecedented Sherman Act antitrust argument, asserting that the law enriches physicians at NPs’ expense rather than protecting patients. If successful, it would end a system that forces practice-owning NPs to pay monthly fees often exceeding $2,000, a barrier that restricts full practice authority and limits care in Texas’s underserved communities.

The 2026 Texas NP Lawsuit: The Key Facts and Docket Status

On July 22, 2026, nurse practitioner Sandy McCoy and the Texas Nurse Practitioners association filed a lawsuit in Travis County District Court challenging the state’s collaborative practice agreement law. McCoy, who has over 30 years of experience, opened her own practice in Plano, and the suit argues that the requirement to maintain a physician agreement, often with significant supervising physician fees, violates her constitutional right to earn a living.

The Filing

The case, McCoy v. Carlton, names Stephen Brint Carlton and other state officials as defendants. Carlton is the executive director of the Texas Medical Board, which enforces the supervision rules. The plaintiffs are represented by the Pacific Legal Foundation (PLF), a nonprofit public-interest law firm that provides its services free of charge. PLF senior attorney Donna Matias leads the legal team.

Legal Claims

The complaint asserts three primary legal theories:

Texas Constitution Due Course of Law: The requirement to maintain a costly physician agreement burdens NPs’ fundamental right to pursue their occupation without adequate justification.
Private Nondelegation Doctrine: The law improperly delegates governmental authority to private physicians, who have a financial incentive to limit competition from NPs.
Sherman Act Antitrust Count: This novel claim alleges that mandatory physician supervision contracts constitute an unreasonable restraint of trade, inflating healthcare costs and restricting patient access. It represents a federal antitrust challenge rarely applied to healthcare professional regulation.

Current Docket Status

As of August 2026, the case is in its earliest procedural stage. The initial complaint has been filed, but no motions to dismiss, preliminary injunction requests, or scheduling orders have been publicly reported. The Travis County District Clerk’s civil docket tools allow parties and the public to search for filings by name or cause number,¹ but substantive updates are not yet available. Pacific Legal Foundation has not announced any immediate hearings, and the court has not set a timeline for the defendants’ response. The legal community is watching closely, as a ruling on the Sherman Act claims could have national implications for the push toward full practice authority states.

Texas had 30,498 actively licensed nurse practitioners in 2023. Each must secure a costly physician delegation agreement to practice, according to the Texas Healthcare Workforce Report from the Office of the Governor.

Understanding Texas Delegation Agreements and Physician Gatekeeper Fees

What does a Texas nurse practitioner actually have to agree to, and pay for, just to practice? The answer lies in delegation agreements, a web of rules rooted in the Texas Occupations Code and administrative regulations that give physicians final say over an NP's ability to work.

The Legal Backbone: Texas Occupations Code and Nursing Board Rules

Texas NPs must operate under a written delegation agreement with a supervising physician, as required by Chapter 157 of the Occupations Code and detailed in 22 Texas Administrative Code Chapter 193. These statutes don't just suggest collaboration; they mandate a formal, signed, and continuously maintained contract. The physician must register the agreement with the Texas Medical Board within 30 days and notify the board within 30 days if it ends.¹ The agreement must be kept on-site and reviewed at least annually⁵, a recurring administrative hoop that keeps both parties tethered.

What's Inside a Delegation Agreement

The required contents leave little room for independent judgment. The contract must describe the specific delegated acts and procedures the NP may perform, the physician's supervision parameters, and the protocols for handling emergencies.⁴ If prescriptive authority is granted, it falls under §193.7, which allows delegation of prescribing or ordering drugs under supervision.² The NP must disclose any prior disciplinary actions and commit to practicing within the agreement's scope of practice and protocols. Quality assurance measures are also mandatory, meaning the physician has ongoing oversight obligations. In short, the agreement is not a loose collaboration: it's a tightly controlled permission slip.

The Gatekeeper Fee: A Private Contract with Public Consequences

Nowhere in Texas law is a fee table published. The payment a physician receives is strictly a private contract term³, but it's widespread practice. Physicians typically charge monthly or annual fees, often ranging from hundreds to over a thousand dollars per month, for the service of acting as a delegating supervisor. They justify the cost by pointing to the administrative workload, reviewing charts, maintaining protocols, updating the agreement, and, more importantly, the malpractice liability they assume for the NP's actions. Yet this arrangement places physicians in the role of paid gatekeepers. They have a financial incentive to limit the number of NPs they work with or to charge high fees that price many NPs out of independent practice, especially in rural or underserved areas. The outcome: a market where an NP's right to earn a living is filtered through a physician's permission, often at a significant recurring cost that strains practice budgets and can ultimately reduce patient access.

How Much Do NPs Actually Pay for Supervising Physicians in Texas?

For Texas NPs who want to run their own practice, the math is simple but brutal: either take a salaried position and surrender autonomy, or pay a physician a monthly gatekeeper fee that can consume a third of your revenue. These fees are the hidden tax on NP independence and are often non-negotiable.

Typical Monthly Retainer Ranges

While every collaborative agreement is unique, Texas NP supervision fees commonly fall between $1,500 and $2,500 per month. That annualizes to $12,000 to $30,000 before any additional charges.¹ Primary care NPs often report lower-end rates, while specialty practices and those in saturated urban markets see fees creep toward the top of the range. Rural NPs sometimes pay less, but the limited pool of available physicians can still drive costs up.

Primary care: $1,500, $2,000 per month, or $18,000, $24,000 annually.
Psychiatric and high-acuity specialties: Easily $2,000, $2,500 per month, or $24,000, $30,000 annually.

Additional Costs: Hourly and Per-Chart Fees

The base retainer is rarely the whole picture. Many supervising physicians add hourly chart-review fees ($150, $400 per hour) or per-chart charges ($5, $20 per chart). A busy NP seeing 20 patients a day can tack on hundreds more each month, turning a $2,000 retainer into a $3,000+ monthly bill.

An Extreme Example: The $96,000 Burden

Texas-specific data is thin, but reports from other states show how dire these arrangements can become. One NP, Terri DeNeui, has publicly stated she pays $96,000 per year ($8,000 a month) for physician oversight. While not documented in Texas, such an amount would instantly destroy most independent NP clinics. Even at the lower Texas ranges, the fee structure forces many NPs to stay in employed hospital roles rather than risk going out on their own.

Why Texas Fees Stay Elevated

A key driver is Texas law: physician-to-NP ratio caps limit how many NPs one doctor can supervise.² This artificially constricts supply, letting physicians charge what the market will bear. Unlike in full practice authority states, where NPs keep their full revenue, Texas NPs essentially rent their license from a physician each month. The result? Money that could fund community clinics or expand patient access flows instead into a legally mandated middleman.

Sherman Act Claims: A Federal Antitrust Challenge to Physician Supervision

How does the Sherman Act apply to Texas's collaborative practice agreement law for nurse practitioners?

The Sherman Act Section 1 Argument

In McCoy v. Carlton, the plaintiffs argue that Texas’s mandatory collaborative practice agreement scheme violates Section 1 of the Sherman Act. A Section 1 claim requires concerted action that unreasonably restrains trade. Here, the complaint frames the physician supervision requirement as a market restriction, not just a licensing rule: it forces nurse practitioners to secure and maintain a paid relationship with a competing profession (physicians) in order to practice. This arrangement, the plaintiffs contend, results in an unlawful restraint of trade in the market for medical services, limiting competition and driving up costs without improving patient care. Such requirements keep Texas out of the group of full practice authority states.

How the Federal Claim Differs from State Constitutional Claims

The lawsuit also raises state constitutional claims under the Texas Constitution’s Due Course of Law Clause and the private nondelegation doctrine. Those claims focus on the individual right to earn a living and the improper delegation of government power to private physicians with financial conflicts of interest. The Sherman Act claim, by contrast, targets the economic structure of the delegation system itself. It argues that the state-mandated gatekeeper model constitutes an agreement among physicians, or between physicians and the state, that restrains trade. This federal count is a strategic addition: it opens the door to federal question jurisdiction, allows for treble damages, and puts the economic impact of the collaboration requirement under antitrust scrutiny.³

Healthcare Antitrust Precedents and the Road Ahead

Antitrust challenges in healthcare are fact-dependent and have faced mixed results.² The U.S. Supreme Court held in American Medical Association v. United States that the Sherman Act can apply to medical association conduct, and in Summit Health, Ltd. v. Pinhas, the Court allowed a physician’s antitrust claim stemming from peer-review and exclusion disputes to proceed. However, more recent cases like the ABMS maintenance-of-certification litigation show the difficulty of pleading an actual agreement: courts dismissed claims because hospitals and insurers independently requiring certification was viewed as parallel conduct, not a conspiracy.¹ A successful Sherman Act challenge in McCoy v. Carlton will likely need to allege specific collusive behavior, market foreclosure, or tangible anticompetitive effects like higher prices or reduced access. The Pacific Legal Foundation, which has a strong track record in economic liberty cases, is well-versed in these requirements and has included the federal claim to maximize the lawsuit’s impact and legal avenues.³

Prior NP Autonomy Legal Battles and Their Outcomes

Staying current on nurse practitioner autonomy lawsuits is challenging: outcomes shift rapidly and biased summaries abound. The most impactful rulings have come through antitrust challenges rather than direct constitutional attacks, and knowing where to look for updates is essential for practicing NPs and educators alike.

Where to Find Current NP Autonomy Litigation

To bypass outdated or incomplete case lists, start with the American Association of Nurse Practitioners (AANP) and your state nursing board’s website. Both publish updates on scope-of-practice litigation and legislative changes, offering a filtered view of what’s truly active. For deeper dives, turn to Google Scholar or CourtListener. Use targeted queries like “nurse practitioner supervision antitrust lawsuit Texas” to locate primary court rulings and determine whether they set binding precedent.

Tracking Pending and Recent Cases

For pending or recent cases, especially those advancing constitutional or antitrust claims against supervision requirements, consult federal and state court records through PACER or its free alternative, RECAP. These tools let you see dockets in real time, ensuring you don’t miss filings like the 2026 Texas NP lawsuit.

Examining Opposing Arguments

Keep in mind that professional associations such as the American Medical Association often publish opposing arguments and amicus briefs. To avoid bias, cross-reference with academic legal databases like LexisNexis or Westlaw, accessible through public or university libraries.

The Precedent Gap: Why This Matters

No U.S. Supreme Court case has ever struck down physician supervision requirements for NPs on constitutional grounds. Instead, landmark antitrust rulings like Goldfarb v. Virginia State Bar (1975)¹ and Arizona v. Maricopa County Medical Society (1982)² establish that professional groups are not immune from the Sherman Act, while North Carolina State Board of Dental Examiners v. FTC (2015)³ demands active state supervision of boards controlled by market participants. Together, these precedents underpin the current Texas challenge but leave a gap that future court decisions could fill.