By: Harris of Tarrant, Moncrief S.B. No. 208
Zaffirini
A BILL TO BE ENTITLED
AN ACT
1-1 relating to the offense of insurance claim fraud; providing a
1-2 criminal penalty.
1-3 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-4 SECTION 1. Subchapter D, Chapter 32, Penal Code, is amended
1-5 by adding Section 32.55 to read as follows:
1-6 Sec. 32.55. INSURANCE CLAIM FRAUD. (a) A person commits an
1-7 offense if the person, with intent to injure, defraud, or deceive
1-8 an insurer, prepares or presents to an insurer in support of a
1-9 claim for payment under a health insurance policy a statement that
1-10 the person knows:
1-11 (1) contains false or misleading information
1-12 concerning a matter that is material to the claim; or
1-13 (2) conceals or fails to disclose a material fact that
1-14 affects:
1-15 (A) a person's right to a payment; or
1-16 (B) the amount of a payment to which a person is
1-17 entitled.
1-18 (b) A person commits an offense if the person, with the
1-19 intent to injure, defraud, or deceive an insurer, solicits, offers,
1-20 pays, or receives a benefit in connection with the furnishing of
1-21 health care goods or services for which payment is sought under an
1-22 insurance policy.
1-23 (c) For the purposes of Subsection (a) of this section,
1-24 information concerning a matter that is material to a claim for
2-1 payment under an insurance policy includes information concerning:
2-2 (1) whether health care goods or services were
2-3 medically necessary under professionally accepted standards;
2-4 (2) whether health care goods or services were
2-5 provided;
2-6 (3) the nature of the health care goods or services
2-7 provided;
2-8 (4) the date on which health care goods or services
2-9 were provided;
2-10 (5) the medical record of goods or services provided;
2-11 (6) the condition treated or diagnosis made; or
2-12 (7) the identity of the provider or the recipient of
2-13 health care goods or services.
2-14 (d) Except as provided by Subsection (e) of this section, an
2-15 offense under this section is:
2-16 (1) a Class C misdemeanor if the value of the claim is
2-17 less than $20;
2-18 (2) a Class B misdemeanor if:
2-19 (A) the value of the claim is $20 or more but
2-20 less than $200; or
2-21 (B) the value of the claim is less than $20 and
2-22 the actor has been previously convicted of a misdemeanor under this
2-23 section;
2-24 (3) a Class A misdemeanor if the value of the claim is
2-25 $200 or more but less than $750;
2-26 (4) a felony of the third degree if:
2-27 (A) the value of the claim is $750 or more but
3-1 less than $20,000; or
3-2 (B) the value of the claim is less than $750 and
3-3 the actor has been previously convicted of a misdemeanor two or
3-4 more times under this section;
3-5 (5) a felony of the second degree if the value of the
3-6 claim is $20,000 or more but less than $100,000; or
3-7 (6) a felony of the first degree if:
3-8 (A) the value of the claim is $100,000 or more;
3-9 (B) the value of the claim is less than $100,000
3-10 and the actor has been previously convicted of a felony under this
3-11 section; or
3-12 (C) the value of the claim is less than $100,000
3-13 and the commission of the offense placed a person at risk of death
3-14 or serious bodily injury.
3-15 (e) An offense under this section is, if the actor is a
3-16 health care practitioner:
3-17 (1) a felony of the third degree if the value of the
3-18 claim is less than $20,000;
3-19 (2) a felony of the second degree if the value of the
3-20 claim is $20,000 or more but less than $100,000; or
3-21 (3) a felony of the first degree if:
3-22 (A) the value of the claim is $100,000 or more;
3-23 (B) the value of the claim is less than $100,000
3-24 and the actor has been previously convicted of an offense under
3-25 this section; or
3-26 (C) the value of the claim is less than $100,000
3-27 and the commission of the offense placed a person at risk of death
4-1 or serious bodily injury.
4-2 (f) In this section:
4-3 (1) "Insurer" means any person who does business as an
4-4 insurer in this state, including an insurer that is not authorized
4-5 to do business in this state. The term includes a health
4-6 maintenance organization, a company subject to Chapter 20,
4-7 Insurance Code, and an organization that is self-insured and that
4-8 provides health care benefits to its employees.
4-9 (2) "Health care practitioner" means a person who
4-10 renders or causes to be rendered health care or mental health care
4-11 services and who is entitled to payment under a health insurance
4-12 policy. The term includes:
4-13 (A) any person who may be selected by an insured
4-14 or a beneficiary under Article 21.52, Insurance Code; and
4-15 (B) an officer, employee, or agent of an
4-16 organization that renders health care or mental health care
4-17 services.
4-18 (3) "Statement" means any written representation of
4-19 fact, including a notice, proof of loss, bill of lading, receipt
4-20 for payment, invoice, account, estimate of property damages, bill
4-21 for services, diagnosis, prescription, medical record, X-ray, test
4-22 result, or other evidence of loss, injury, or expense. A statement
4-23 may be computer-generated.
4-24 SECTION 2. The change in law made by Section 32.55, Penal
4-25 Code, as added by this Act, applies only to the punishment for an
4-26 offense committed on or after the effective date of this Act. For
4-27 the purpose of this section, an offense is committed before the
5-1 effective date of this Act if any element of the offense occurs
5-2 before the effective date. An offense committed before the
5-3 effective date of this Act is covered by the law in effect when the
5-4 offense was committed, and the former law is continued in effect
5-5 for this purpose.
5-6 SECTION 3. This Act takes effect September 1, 1993.
5-7 SECTION 4. The importance of this legislation and the
5-8 crowded condition of the calendars in both houses create an
5-9 emergency and an imperative public necessity that the
5-10 constitutional rule requiring bills to be read on three several
5-11 days in each house be suspended, and this rule is hereby suspended.