By: Harris of Tarrant, Moncrief S.B. No. 206
Zaffirini
A BILL TO BE ENTITLED
AN ACT
1-1 relating to claims, review of claims, and fraudulent claims for
1-2 benefits for certain health care and mental health care services
1-3 covered by insurance; imposing civil and criminal penalties.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Subchapter C, Chapter 21, Insurance Code, is
1-6 amended by adding Article 21.24-2 to read as follows:
1-7 Art. 21.24-2. SETTLEMENT OF CLAIMS FOR HEALTH CARE SERVICES
1-8 Sec. 1. DEFINITIONS. In this article:
1-9 (1) "Health care provider" means a person providing
1-10 health care services who is eligible for reimbursement for those
1-11 services from an insurer.
1-12 (2) "Insured" means the policyholder in the case of an
1-13 individual policy of insurance and the certificate holder in the
1-14 case of a group policy of insurance.
1-15 (3) "Insurer" means a person who is authorized to
1-16 write an individual or group policy of insurance that is delivered,
1-17 issued for delivery, or renewed in this state and that provides
1-18 coverage for medical or surgical expenses incurred as a result of
1-19 accident or sickness, including a company subject to Chapter 20 of
1-20 this code and a health maintenance organization subject to the
1-21 Texas Health Maintenance Organization Act (Chapter 20A, Vernon's
1-22 Texas Insurance Code).
1-23 Sec. 2. NOTICE OF AMOUNT PAID. An insurer shall notify the
1-24 insured in writing of the amount billed by a health care provider
2-1 and actually paid by the insurer for health care services provided
2-2 under the insured's coverage.
2-3 Sec. 3. ADJUSTMENT OF DEDUCTIBLE OR COPAYMENT. If an
2-4 insured pays a deductible or copayment for health care services and
2-5 the amount actually paid by the insurer for those services is
2-6 adjusted, the health care provider shall refund to the insured any
2-7 amount of the deductible or copayment paid by the insured in excess
2-8 of the amount required to be paid under the policy for those
2-9 services. At the time of the adjustment, the insurer shall notify
2-10 the health care provider of the adjustment and provide the health
2-11 care provider with a statement of the deductible and copayment
2-12 requirements applicable to the insured, as well as any other
2-13 information necessary for the health care provider to make the
2-14 appropriate refund to the insured.
2-15 SECTION 2. Subchapter C, Chapter 21, Insurance Code, is
2-16 amended by adding Article 21.24-3 to read as follows:
2-17 Art. 21.24-3. WAIVER OR REDUCTION OF COPAYMENT OR DEDUCTIBLE
2-18 PROHIBITED
2-19 Sec. 1. DEFINITIONS. In this article:
2-20 (1) "Health care provider" means a person providing
2-21 health care services who is eligible for reimbursement for those
2-22 services from an insurer or who provides services to enrollees of
2-23 health care plans.
2-24 (2) "Enrollee" means an individual who is enrolled in
2-25 a health care plan.
2-26 (3) "Health care plan" has the meaning assigned by
2-27 Section 2, Texas Health Maintenance Organization Act (Article
3-1 20A.02, Vernon's Texas Insurance Code).
3-2 (4) "Health insurance policy" means an individual or
3-3 group policy of insurance that provides coverage for medical or
3-4 surgical expenses incurred as a result of accident or sickness,
3-5 including a policy issued by a group hospital service corporation.
3-6 (5) "Insured" means a policyholder in the case of an
3-7 individual health insurance policy and the certificate holder in
3-8 the case of a group health insurance policy.
3-9 Sec. 2. WAIVER OR REDUCTION OF COPAYMENT OR DEDUCTIBLE.
3-10 (a) A health care provider may not waive or reduce a copayment,
3-11 deductible, or similar fee required under a health insurance policy
3-12 or health care plan.
3-13 (b) A health care provider may not represent to an insured
3-14 or enrollee that a waiver or reduction in violation of Subsection
3-15 (a) of this section is permissible.
3-16 (c) A health care provider has waived a copayment,
3-17 deductible, or similar fee in violation of Subsection (a) of this
3-18 section if the provider knowingly fails to follow standard business
3-19 practices to collect the copayment, deductible, or similar fee.
3-20 Sec. 3. PENALTIES. (a) A person who violates this article
3-21 commits an offense. An offense under this subsection is a Class B
3-22 misdemeanor.
3-23 (b) A person who violates this article commits an unfair
3-24 method of competition and unfair and deceptive act or practice for
3-25 purposes of Article 21.21, Insurance Code.
3-26 (c) A person who violates this article commits a false,
3-27 misleading, or deceptive act or practice for purposes of Subchapter
4-1 E, Chapter 17, Business & Commerce Code.
4-2 SECTION 3. Subtitle B, Title 2, Health and Safety Code, is
4-3 amended by adding Chapter 45 to read as follows:
4-4 CHAPTER 45. AUDIT OF HOSPITALS
4-5 Sec. 45.001. AUDIT OF HOSPITAL. (a) If a utilization
4-6 review agent certified under Article 21.58A, Insurance Code,
4-7 conducts an audit of hospital billings in conjunction with a
4-8 utilization review, the agent shall report any adverse results of
4-9 the audit to the state agency that licenses the hospital.
4-10 (b) The department shall adopt criteria for reports made
4-11 under this section, including criteria to determine whether a
4-12 report of adverse results of an audit must be made, in consultation
4-13 with the Texas Department of Mental Health and Mental Retardation
4-14 and the Texas Commission on Alcohol and Drug Abuse.
4-15 SECTION 4. Section 9, Article 21.58A, Insurance Code, is
4-16 amended to read as follows:
4-17 Sec. 9. VIOLATIONS. <(a) If the commissioner believes that
4-18 a utilization review agent has violated or is violating this
4-19 article, the commissioner shall notify the utilization review agent
4-20 of the alleged violation and may compel the production of any and
4-21 all documents or other information as provided by this code.>
4-22 <(b) The commissioner may initiate the proceedings under
4-23 this section after the 30th day after the date the commissioner
4-24 notifies the agent as required by Subsection (a) of this section.>
4-25 <(c) Proceedings under this article are a contested case for
4-26 the purposes of the administrative procedure act.>
4-27 <(d)> If a <after notice and hearing the commissioner
5-1 determines that the> utilization review agent has violated or is
5-2 violating any provision of this article, the commissioner may<:>
5-3 <(1)> impose sanctions under Section 7, Article 1.10
5-4 of this code<;> or
5-5 <(2) issue a cease and desist order> under Article
5-6 1.10A of this code.
5-7 SECTION 5. Section 11, Article 21.58A, Insurance Code, is
5-8 amended by adding Subsection (c) to read as follows:
5-9 (c) The board shall adopt guidelines and procedures for
5-10 utilization reviews conducted after a health care service has been
5-11 provided to an enrollee.
5-12 SECTION 6. Article 21.58A, Insurance Code, is amended by
5-13 adding Section 13A to read as follows:
5-14 Sec. 13A. REPORTING OF INFORMATION RELATING TO PATIENT CARE;
5-15 IMMUNITY. (a) For the purpose of this section, "quality assurance
5-16 entity" means any person, committee, division, department, or other
5-17 entity responsible for quality assurance or peer review of services
5-18 provided by a health care provider.
5-19 (b) A utilization review agent may report to a quality
5-20 assurance entity information gathered by the utilization review
5-21 agent that relates to a specific patient and that is relevant to
5-22 the quality of care received by the patient. The utilization
5-23 review agent may require that the quality assurance entity ensure
5-24 compliance with confidentiality requirements imposed by law,
5-25 including the requirements of Sections 161.032 and 611.002, Health
5-26 and Safety Code, and Section 5.06, Medical Practice Act (Article
5-27 4495b, Vernon's Texas Civil Statutes).
6-1 (c) Information provided by a utilization review agent to a
6-2 peer review committee under Section 5.06, Medical Practice Act
6-3 (Article 4495b, Vernon's Texas Civil Statutes), is subject to the
6-4 confidentiality requirements of that section.
6-5 (d) Except as provided by Section 5.06, Medical Practice Act
6-6 (Article 4495b, Vernon's Texas Civil Statutes), a utilization
6-7 review agent is not subject to liability for providing information
6-8 to a quality assurance entity.
6-9 SECTION 7. Section 2, Article 1.10A, Insurance Code, is
6-10 amended to read as follows:
6-11 Sec. 2. Authority To Issue Order. The commissioner may
6-12 issue an emergency cease and desist order, ex parte, if:
6-13 (1) the commissioner believes:
6-14 (A) an authorized person engaging in the
6-15 business of insurance is committing an unfair method of competition
6-16 or an unfair or deceptive act or practice in violation of Article
6-17 21.21 or Article 21.21-2 of this code or in violation of a rule or
6-18 regulation promulgated under Article 21.21 or Article 21.21-2 of
6-19 this code;
6-20 (B) an unauthorized person is engaging in the
6-21 business of insurance in violation of Article 1.14-1 of this code
6-22 or in violation of a rule or regulation promulgated under Article
6-23 1.14-1 of this code;
6-24 (C) an unauthorized person engaged in the
6-25 business of insurance acting in violation of Article 1.14-1 of this
6-26 code is committing an unfair method of competition or an unfair or
6-27 deceptive act or practice in violation of Article 21.21 or Article
7-1 21.21-2 of this code or in violation of any rule or regulation
7-2 promulgated under Article 21.21 or Article 21.21-2 of this code;
7-3 <or>
7-4 (D) an authorized person engaging in the
7-5 business of insurance is determined by the commissioner to be in a
7-6 hazardous condition or a hazardous financial condition under
7-7 Article 1.32 or Article 20A.19 of this code; or
7-8 (E) a person is violating Article 21.58A of this
7-9 code or a rule adopted under Article 21.58A of this code; and
7-10 (2) it appears to the commissioner that the alleged
7-11 conduct is fraudulent or hazardous or creates an immediate danger
7-12 to the public safety or is causing or can be reasonably expected to
7-13 cause significant, imminent, and irreparable public injury.
7-14 SECTION 8. Title 2, Health and Safety Code, is amended by
7-15 adding Subtitle I to read as follows:
7-16 SUBTITLE I. SPECIAL PROVISIONS
7-17 CHAPTER 180. DEPARTMENT REVIEW OF
7-18 MENTAL HEALTH BENEFITS CLAIMS
7-19 Sec. 180.001. DEFINITIONS. In this chapter:
7-20 (1) "Insured" means a person who makes a mental health
7-21 benefits claim.
7-22 (2) "Insurer" means an insurer that writes an
7-23 individual or group policy of insurance that is delivered, issued
7-24 for delivery, or renewed in this state, including a company subject
7-25 to Chapter 20, Insurance Code, and a health maintenance
7-26 organization subject to the Texas Health Maintenance Organization
7-27 Act (Chapter 20A, Vernon's Texas Insurance Code).
8-1 (3) "Mental health benefits claim" means a claim made
8-2 under an insurance policy for benefits for the treatment of a
8-3 mental or emotional disorder, including a serious mental illness as
8-4 defined by Article 3.51-14, Insurance Code.
8-5 (4) "Mental health benefits invoice" means an invoice
8-6 for goods or services provided to an insured for the treatment of a
8-7 mental or emotional disorder, including a serious mental illness as
8-8 defined by Article 3.51-14, Insurance Code. The term includes an
8-9 invoice that is provided to an assignee of the insured.
8-10 Sec. 180.002. CLAIM REVIEW. (a) On request and in
8-11 accordance with this section, the department may review a mental
8-12 health benefits invoice.
8-13 (b) Not later than the 30th day after the date an insured
8-14 notifies an insurer of a mental health benefits claim, the insurer
8-15 may request that the department conduct a review of the invoice
8-16 under this section. The department shall adopt rules establishing
8-17 criteria for when review may be requested by an insurer under this
8-18 subsection and what documentation the insurer must provide in
8-19 connection with the request to demonstrate that those criteria have
8-20 been satisfied.
8-21 (c) Not later than the 30th day after the date the insurer
8-22 notifies an insured that the insurer has denied all or part of a
8-23 mental health benefits claim, the insured may request that the
8-24 department conduct a review of the invoice under this section.
8-25 This subsection does not apply to an invoice for which the insurer
8-26 has requested a review under Subsection (b) of this section.
8-27 (d) Not later than the 30th day after the date the
9-1 department receives a request from an insured under Subsection (c)
9-2 of this section, the department shall mail a notice to the affected
9-3 insurer, advising the insurer of the request.
9-4 (e) The department shall report a person to the office of
9-5 attorney general and to the Texas Department of Mental Health and
9-6 Mental Retardation or other appropriate state agency if the
9-7 department finds, as a result of a review conducted under this
9-8 section, that the person participated in the issuance of a mental
9-9 health benefits invoice that the person knows:
9-10 (1) does not accurately reflect the services or
9-11 products provided;
9-12 (2) includes a service or product that should not have
9-13 been provided; or
9-14 (3) includes an unreasonable charge for a service or
9-15 product.
9-16 (f) The board shall adopt rules governing hearings and
9-17 reviews conducted under this article.
9-18 (g) This section does not limit the right of an insured to
9-19 bring an action in a court to enforce the insured's rights against
9-20 an insurer. An insured is not required to request review under
9-21 this article before bringing an action in court. Regardless of
9-22 whether a review has been conducted under Subsection (c) of this
9-23 section, the insured is entitled to trial de novo with respect to
9-24 any matter that was the subject of the review.
9-25 (h) The request for an investigation pursuant to this
9-26 article shall not relieve the insurer from any payment obligations,
9-27 including without limitation those set forth in Article 21.55 of
10-1 this code.
10-2 SECTION 9. Subchapter E, Chapter 21, Insurance Code, is
10-3 amended by adding Article 21.58D to read as follows:
10-4 Art. 21.58D. Insurer Investigation of Health Benefits Claims
10-5 Sec. 1. Definitions. In this article:
10-6 (1) "Health benefits claim" means a claim made under
10-7 an insurance policy for benefits for the treatment of an illness or
10-8 injury, including a serious mental illness as defined by Article
10-9 3.51-14 of this code or any other mental or emotional disorder.
10-10 (2) "Health benefits invoice" means an invoice for
10-11 goods or services provided to an insured for the treatment of an
10-12 illness or injury, including a mental or emotional disorder. The
10-13 term includes an invoice that is provided to an assignee of the
10-14 insured.
10-15 (3) "Insured" means a person making a health benefits
10-16 claim under an insurance policy.
10-17 (4) "Insurer" means an insurer that writes an
10-18 individual or group policy of insurance that is delivered, issued
10-19 for delivery, or renewed in this state, including a company subject
10-20 to Chapter 20, Insurance Code, and a health maintenance
10-21 organization subject to the Texas Health Maintenance Organization
10-22 Act (Chapter 20A, Vernon's Texas Insurance Code).
10-23 Sec. 2. Investigation. (a) An insurer shall investigate a
10-24 claim submitted to the insurer if the insured requests an
10-25 investigation under this section.
10-26 (b) An insured may request that the insurer investigate
10-27 whether the health benefits invoice on which the claim is based:
11-1 (1) accurately reflects the services or products
11-2 provided;
11-3 (2) includes a service or product that should not have
11-4 been provided; or
11-5 (3) includes an unreasonable charge for a service or
11-6 product.
11-7 (c) The insured must make the request for investigation not
11-8 later than the 30th day after the date on which:
11-9 (1) the insured mailed or delivered the claim to the
11-10 insurer; or
11-11 (2) the insured received notice of a claim filed by a
11-12 health care provider under an assignment of benefits.
11-13 (d) The insurer shall report the results of the
11-14 investigation to the insured, the department, the provider, and the
11-15 Texas Department of Health, Texas Department of Mental Health and
11-16 Mental Retardation, or other appropriate state agency.
11-17 Sec. 3. NOTIFICATION OF RIGHT TO INVESTIGATION. (a) Each
11-18 individual policy of insurance, certificate evidencing coverage
11-19 under a group policy of insurance, and evidence of coverage issued
11-20 by a health maintenance organization that is delivered, issued for
11-21 delivery, or renewed by an insurer in this state must include a
11-22 statement of an insured's right to an investigation under this
11-23 article.
11-24 (b) A notice of the amount billed provided to an insured
11-25 under Section 2, Article 21.24-2, of this code must include a
11-26 statement of the insured's right to an investigation under this
11-27 article.
12-1 (c) The board shall adopt rules governing the form and
12-2 content of the statement included in the policy, certificate,
12-3 evidence of coverage, or notice under this article.
12-4 SECTION 10. Subchapter E, Chapter 21, Insurance Code, is
12-5 amended by adding Articles 21.79, 21.79A, 21.79A-1, and 21.79A-2 to
12-6 read as follows:
12-7 Art. 21.79. CIVIL ACTIONS FOR INSURANCE CLAIM FRAUD
12-8 Sec. 1. DEFINITION. For purposes of this article, "health
12-9 care practitioner" means a person who renders or causes to be
12-10 rendered health care or mental health care services and who is
12-11 entitled to payment under a health insurance policy and includes
12-12 any person who may be selected by an insured or beneficiary under
12-13 Article 21.52 of this code. The term also includes a person who is
12-14 an officer, employee, or agent of an organization that renders
12-15 health care or mental health care services.
12-16 Sec. 2. CAUSES OF ACTION. (a) A person who is injured by
12-17 an act of fraud in connection with an insurance claim may bring an
12-18 action in a court of competent jurisdiction for damages and may
12-19 petition the court to restrain further attempts to make an improper
12-20 claim for payment.
12-21 (b) A person who has received medical treatment wrongfully
12-22 or unnecessarily at the direction of a health care practitioner may
12-23 bring an action in a court of competent jurisdiction for damages or
12-24 to enjoin further wrongful acts.
12-25 Sec. 3. DAMAGES. (a) In an action filed under this
12-26 article, the court may grant a successful claimant:
12-27 (1) compensatory damages plus all reasonable
13-1 investigation and litigation expenses, including attorney fees;
13-2 (2) an order restraining the respondent from engaging
13-3 in further attempts to make an improper claim for payment;
13-4 (3) damages in accordance with Subsection (b) of this
13-5 section; and
13-6 (4) any other relief the court finds proper.
13-7 (b) If the court finds that the respondent has engaged in a
13-8 pattern of committing fraud in connection with insurance claims,
13-9 the court may award the claimant two times the amount of
13-10 compensatory damages awarded under Subsection (a)(1) of this
13-11 section. An award of damages under this subsection is in addition
13-12 to an award of damages under Subsection (a)(1) of this section.
13-13 Sec. 4. LIMITATIONS. (a) Notwithstanding Section 16.003,
13-14 Civil Practice and Remedies Code, a person must bring suit under
13-15 this article on or before the later of:
13-16 (1) four years after the date the fraud occurred; or
13-17 (2) four years after the date the person, in the
13-18 exercise of reasonable diligence, should have discovered the
13-19 occurrence of the fraud.
13-20 (b) The limitations period in this section does not include
13-21 any period during which the person bringing the action reasonably
13-22 believes that the department or another authorized governmental
13-23 agency is conducting a criminal investigation or prosecution of the
13-24 defendant for fraud.
13-25 Sec. 5. NOTICE TO APPROPRIATE AGENCY. (a) Not later than
13-26 the 31st day after a verdict is entered holding a health care
13-27 practitioner liable for damages under this article, the clerk of
14-1 the court in which the verdict is rendered shall prepare and send
14-2 to the licensing authority with jurisdiction over the practitioner
14-3 a certified abstract of the court's record regarding the case.
14-4 (b) On receipt of the abstract of the record, the licensing
14-5 authority shall consider disciplinary action against the health
14-6 care practitioner in accordance with the procedures used by that
14-7 licensing authority.
14-8 Art. 21.79A. HEALTH CARE INSURANCE CLAIM FRAUD; NOTIFICATION
14-9 OF LICENSING AUTHORITY. (a) For purposes of this article, "health
14-10 care practitioner" means a person who renders or causes to be
14-11 rendered health care or mental health care services and who is
14-12 entitled to payment under a health insurance policy. The term
14-13 includes:
14-14 (1) any person who may be selected by an insured or
14-15 beneficiary under Article 21.52 of this code; and
14-16 (2) an officer, employee, or agent of an organization
14-17 that renders health care or mental health care services.
14-18 (b) If the department knows that a health care practitioner
14-19 has been convicted of fraud in connection with an insurance claim,
14-20 the department shall notify the licensing authority with
14-21 jurisdiction over the practitioner of the conviction.
14-22 (c) On receipt of notification under Subsection (b) of this
14-23 article, the licensing authority shall consider disciplinary action
14-24 against the health care practitioner in accordance with the
14-25 procedures used by that licensing authority.
14-26 (d) The department shall cooperate with the licensing
14-27 authority and shall provide any necessary and relevant testimony,
15-1 documents, or other evidence in the possession of the department.
15-2 Art. 21.79A-1. HEALTH CARE INSURANCE CLAIM FRAUD; REPORT OF
15-3 OUT-OF-STATE CONVICTION. (a) For purposes of this article,
15-4 "health care practitioner" means a person who renders or causes to
15-5 be rendered health care or mental health care services and who is
15-6 entitled to payment under a health insurance policy. The term
15-7 includes:
15-8 (1) any person who may be selected by an insured or
15-9 beneficiary under Article 21.52 of this code; and
15-10 (2) an officer, employee, or agent of an organization
15-11 that renders health care or mental health care services.
15-12 (b) If a health care practitioner rendering health care or
15-13 mental health care services in this state is convicted of fraud on
15-14 an insurer in another state, the practitioner shall report the
15-15 conviction in writing to the commissioner.
15-16 (c) A health care practitioner who does not report a
15-17 conviction in accordance with Subsection (b) of this article may be
15-18 disciplined in accordance with the procedures of the licensing
15-19 authority with jurisdiction over the practitioner.
15-20 Art. 21.79A-2. HEALTH CARE INSURANCE CLAIM FRAUD; HEALTH
15-21 CARE PRACTITIONER COOPERATION IN INVESTIGATION. (a) In this
15-22 article:
15-23 (1) "Health benefits claim" means a claim made under
15-24 an insurance policy for benefits for the treatment of an illness or
15-25 injury, including a mental or emotional disorder.
15-26 (2) "Health benefits claim investigation" means an
15-27 investigation of a health benefits claim conducted by:
16-1 (A) a law enforcement agency of this state;
16-2 (B) an insurer;
16-3 (C) the insurance fraud unit created under
16-4 Article 1.10D of this code;
16-5 (D) the office of the attorney general; or
16-6 (E) a state or federal governmental agency or a
16-7 nongovernmental agency established to detect and prevent fraudulent
16-8 insurance acts or to regulate the business of insurance.
16-9 (3) "Health care practitioner" means a person who
16-10 renders or causes to be rendered health care or mental health care
16-11 services and who is entitled to payment under a health insurance
16-12 policy. The term includes:
16-13 (A) any person who may be selected by an insured
16-14 or beneficiary under Article 21.52 of this code; and
16-15 (B) an officer, employee, or agent of an
16-16 organization that renders health care or mental health care
16-17 services.
16-18 (4) "Investigating agency" means the person conducting
16-19 the health benefits claim investigation.
16-20 (b) Not later than the 31st day after the date on which a
16-21 health care practitioner receives a request for information from an
16-22 investigating agency that relates to a health benefits claim
16-23 investigation, the health care practitioner shall provide the
16-24 information to the agency.
16-25 (c) If the health care practitioner does not provide the
16-26 requested information within the time specified by Subsection (b)
16-27 of this article, a court of this state, on the petition of the
17-1 investigating agency, shall order the health care practitioner to
17-2 provide the information unless the health care practitioner
17-3 demonstrates that the information is not available or that the
17-4 information may not be released under state or federal law.
17-5 (d) A court issuing an order under Subsection (c) of this
17-6 article also shall order the health care practitioner to pay
17-7 reasonable attorney fees and costs incurred by the investigating
17-8 agency in obtaining the order. The order may include appropriate
17-9 limits on the distribution of confidential communications.
17-10 (e) If the health benefits claim is the subject of a
17-11 criminal or civil court proceeding at the time a court order is
17-12 sought under Subsection (c) of this article, the petition for an
17-13 order under Subsection (c) of this article must be made in the
17-14 court in which the claim is pending.
17-15 SECTION 11. Subsection (e), Section 2, Article 1.10D,
17-16 Insurance Code, is amended to read as follows:
17-17 (e) This section does not prohibit or limit the authority
17-18 of an insurer to conduct its own independent investigation into a
17-19 suspected case of insurance claim fraud. Before an insurer may
17-20 request the commissioner to conduct an investigation of suspected
17-21 claim fraud, the insurer must have completed its investigation and
17-22 drafted a report of its findings. The insurer shall submit the
17-23 report and the related investigation file to the commissioner as
17-24 part of the insurer's request for investigation by the
17-25 commissioner. The commissioner may undertake an investigation
17-26 against a policyholder or claimant only if:
17-27 (1) <In regard to an insurer's request for
18-1 investigation under this subsection, the commissioner's authority
18-2 to undertake an investigation against a policyholder or claimant is
18-3 limited to those instances in which> the insurer's investigation
18-4 reports show a pattern of fraudulent activity; or
18-5 (2) the total amount of allegedly fraudulent claims is
18-6 at least $25,000.
18-7 SECTION 12. Section 5, Article 1.10D, Insurance Code, is
18-8 amended by adding Subsection (d) to read as follows:
18-9 (d) The insurance fraud unit may provide information or
18-10 material that is relevant to an inquiry into claim fraud to an
18-11 insurance industry-sponsored fraud investigation unit if the
18-12 commissioner determines that providing the information or material
18-13 would prevent further fraud or otherwise serve the public interest
18-14 and that the interests of the department and of the insurance
18-15 industry-sponsored fraud investigation unit are substantially
18-16 similar with respect to the subject of the investigation. An
18-17 insurance industry-sponsored fraud investigation unit that has
18-18 received information or material under this subsection may not
18-19 release the information or material to a person other than an
18-20 authorized governmental entity. Providing information or material
18-21 under this subsection is not a waiver of confidentiality by the
18-22 department under any part of this code. The department is not
18-23 subject to liability for providing information or material to an
18-24 insurance industry-sponsored fraud investigation unit.
18-25 SECTION 13. Subsection (a), Section 6, Article 1.10D,
18-26 Insurance Code, is amended to read as follows:
18-27 (a) A person acting without malice, fraudulent intent, or
19-1 bad faith is not subject to liability based on filing reports or
19-2 furnishing, orally or in writing, other information concerning
19-3 suspected, anticipated, or completed fraudulent insurance acts if
19-4 the reports or information are provided to:
19-5 (1) a law enforcement officer or an agent or employee
19-6 of a law enforcement officer;
19-7 (2) the National Association of Insurance
19-8 Commissioners, a state or federal governmental agency or
19-9 nongovernmental agency or association established to detect and
19-10 prevent fraudulent insurance acts or to regulate the business of
19-11 insurance, or an employee of that association or <governmental>
19-12 agency; <or>
19-13 (3) an insurer or an agent or an employee of an
19-14 insurer; or
19-15 (4) an authorized governmental agency or the
19-16 department.
19-17 SECTION 14. Section 6, Article 1.10D, Insurance Code, is
19-18 amended by adding Subsection (e) to read as follows:
19-19 (e) In an action brought against a person for filing a
19-20 report or furnishing other information concerning a fraudulent
19-21 insurance act, the party bringing the action must specifically
19-22 plead any allegation that Subsection (a) of this section is
19-23 inapplicable because the person that filed the report or furnished
19-24 the information acted with malice, fraudulent intent, or bad faith.
19-25 SECTION 15. (a) Article 21.24-2, Insurance Code, as added
19-26 by this Act, applies only to amounts paid by an insurer for health
19-27 care services rendered on or after the effective date of this Act.
20-1 Amounts paid by the insurer for health care services rendered
20-2 before the effective date of this Act are governed by the law in
20-3 effect at the time the amounts were paid, and that law is continued
20-4 in effect for that purpose.
20-5 (b) Section 21.24-3, Insurance Code, as added by this Act,
20-6 applies only to conduct that occurs on or after the effective date
20-7 of this Act. Conduct that occurs before the effective date of this
20-8 Act is governed by the law as it existed immediately before the
20-9 effective date of this Act, and that law is continued in effect for
20-10 that purpose.
20-11 (c) Section 9, Article 21.58A, Insurance Code, as amended by
20-12 this Act, applies only to a violation of Article 21.58A that occurs
20-13 on or after the effective date of this Act. A violation of Article
20-14 21.58A, Insurance Code, that occurs before the effective date of
20-15 this Act is governed by the law in effect at the time the violation
20-16 occurs, and that law is continued in effect for that purpose.
20-17 (d) The State Board of Insurance may not adopt rules under
20-18 Subsection (c), Section 11, Article 21.58A, Insurance Code, as
20-19 added by this Act, until the board has reported to the 73rd
20-20 Legislature the findings and recommendations of the study conducted
20-21 by the board in accordance with Subsection (b), Section 11.03,
20-22 Chapter 242, Acts of the 72nd Legislature, Regular Session, 1991.
20-23 (e) Chapter 180, Health and Safety Code, as added by this
20-24 Act, applies only to a mental health benefits claim received by an
20-25 insurer on or after the effective date of this Act. A mental
20-26 health benefits claim received before the effective date of this
20-27 Act is governed by the law in effect at the time the claim was
21-1 received, and that law is continued in effect for that purpose.
21-2 (f) Article 21.58D, Insurance Code, as added by this Act,
21-3 applies only to a health benefits claim received by an insurer on
21-4 or after the effective date of this Act. A health benefits claim
21-5 received before the effective date of this Act is governed by the
21-6 law in effect at the time the claim was received, and that law is
21-7 continued in effect for that purpose.
21-8 (g) Article 21.79, Insurance Code, as added by this Act,
21-9 applies only to a cause of action that accrues on or after the
21-10 effective date of this Act. An action that accrued before the
21-11 effective date of this Act is governed by the law in effect at the
21-12 time the action accrued, and the former law is continued in effect
21-13 for that purpose.
21-14 (h) Article 21.79A-1, Insurance Code, as added by this Act,
21-15 applies to a conviction for fraud on an insurer in another state
21-16 that occurred before, on, or after the effective date of this Act.
21-17 (i) Subsection (e), Section 6, Article 1.10D, Insurance
21-18 Code, as added by this Act, applies only to a pleading filed on or
21-19 after the effective date of this Act. A pleading filed before the
21-20 effective date of this Act is governed by the law in effect at the
21-21 time the pleading was filed, and that law is continued in effect
21-22 for that purpose.
21-23 SECTION 16. This Act takes effect September 1, 1993.
21-24 SECTION 17. The importance of this legislation and the
21-25 crowded condition of the calendars in both houses create an
21-26 emergency and an imperative public necessity that the
21-27 constitutional rule requiring bills to be read on three several
22-1 days in each house be suspended, and this rule is hereby suspended.