By Moncrief S.B. No. 355 74R742 PEP-F A BILL TO BE ENTITLED 1-1 AN ACT 1-2 relating to the offense of insurance claim fraud; providing 1-3 criminal penalties. 1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: 1-5 SECTION 1. Subchapter D, Chapter 32, Penal Code, is amended 1-6 by adding Section 32.55 to read as follows: 1-7 Sec. 32.55. INSURANCE CLAIM FRAUD. (a) A person commits an 1-8 offense if the person, with intent to injure, defraud, or deceive 1-9 an insurer, causes to be prepared or presents to an insurer in 1-10 support of a claim for payment under a health insurance policy a 1-11 statement that the person knows: 1-12 (1) contains false or misleading information 1-13 concerning a matter that is material to the claim; or 1-14 (2) conceals or fails to disclose a material fact that 1-15 affects: 1-16 (A) a person's right to a payment; or 1-17 (B) the amount of a payment to which a person is 1-18 entitled. 1-19 (b) A person commits an offense if the person, with the 1-20 intent to injure, defraud, or deceive an insurer, solicits, offers, 1-21 pays, or receives a benefit in connection with the furnishing of 1-22 health care goods or services for which payment is sought under an 1-23 insurance policy. 1-24 (c) For the purposes of Subsection (a), information 2-1 concerning a matter that is material to a claim for payment under 2-2 an insurance policy includes information concerning: 2-3 (1) whether health care goods or services were 2-4 medically necessary under professionally accepted standards; 2-5 (2) whether health care goods or services were 2-6 provided; 2-7 (3) the nature of the health care goods or services 2-8 provided; 2-9 (4) the date on which health care goods or services 2-10 were provided; 2-11 (5) the medical record of goods or services provided; 2-12 (6) the condition treated or diagnosis made; or 2-13 (7) the identity of the provider or the recipient of 2-14 health care goods or services. 2-15 (d) Except as provided by Subsection (e), an offense under 2-16 this section is: 2-17 (1) a Class C misdemeanor if the value of the claim is 2-18 less than $20; 2-19 (2) a Class B misdemeanor if: 2-20 (A) the value of the claim is $20 or more but 2-21 less than $500; or 2-22 (B) the value of the claim is less than $20 and 2-23 the actor has been previously convicted of a misdemeanor under this 2-24 section; 2-25 (3) a Class A misdemeanor if the value of the claim is 2-26 $500 or more but less than $1,500; 2-27 (4) a state jail felony if: 3-1 (A) the value of the claim is $1,500 or more but 3-2 less than $20,000; or 3-3 (B) the value of the claim is less than $1,500 3-4 and the actor has been previously convicted of a misdemeanor two or 3-5 more times under this section; 3-6 (5) a felony of the third degree if the value of the 3-7 claim is $20,000 or more but less than $100,000; 3-8 (6) a felony of the second degree if the value of the 3-9 claim is $100,000 or more but less than $200,000; or 3-10 (7) a felony of the first degree if: 3-11 (A) the value of the claim is $200,000 or more; 3-12 (B) the value of the claim is less than $200,000 3-13 and the actor has been previously convicted of a felony under this 3-14 section; or 3-15 (C) the value of the claim is less than $200,000 3-16 and the commission of the offense placed a person at risk of death 3-17 or serious bodily injury. 3-18 (e) An offense under this section is, if the actor is a 3-19 health care practitioner: 3-20 (1) a state jail felony if the value of the claim is 3-21 less than $20,000; 3-22 (2) a felony of the third degree if the value of the 3-23 claim is $20,000 or more but less than $100,000; 3-24 (3) a felony of the second degree if the value of the 3-25 claim is $100,000 or more but less than $200,000; or 3-26 (4) a felony of the first degree if: 3-27 (A) the value of the claim is $200,000 or more; 4-1 (B) the value of the claim is less than $200,000 4-2 and the actor has been previously convicted of an offense under 4-3 this section; or 4-4 (C) the value of the claim is less than $200,000 4-5 and the commission of the offense placed a person at risk of death 4-6 or serious bodily injury. 4-7 (f) In this section: 4-8 (1) "Insurer" means any person who does business as an 4-9 insurer in this state, including an insurer that is not authorized 4-10 to do business in this state. The term includes a health 4-11 maintenance organization, a company subject to Chapter 20, 4-12 Insurance Code, and an organization that is self-insured and that 4-13 provides health care benefits to its employees. 4-14 (2) "Health care practitioner" means a person who 4-15 renders or causes to be rendered health care or mental health care 4-16 services and who is entitled to payment under a health insurance 4-17 policy. The term includes: 4-18 (A) any person who may be selected by an insured 4-19 or a beneficiary under Article 21.52, Insurance Code; and 4-20 (B) an officer, employee, or agent of an 4-21 organization that renders health care or mental health care 4-22 services. 4-23 (3) "Statement" means any written representation of 4-24 fact, including a notice, proof of loss, bill of lading, receipt 4-25 for payment, invoice, account, estimate of property damages, bill 4-26 for services, diagnosis, prescription, medical record, X-ray, test 4-27 result, or other evidence of loss, injury, or expense. A statement 5-1 may be computer-generated. 5-2 SECTION 2. The change in law made by Section 32.55, Penal 5-3 Code, as added by this Act, applies only to the punishment for an 5-4 offense committed on or after the effective date of this Act. For 5-5 the purpose of this section, an offense is committed before the 5-6 effective date of this Act if any element of the offense occurs 5-7 before the effective date. An offense committed before the 5-8 effective date of this Act is covered by the law in effect when the 5-9 offense was committed, and the former law is continued in effect 5-10 for this purpose. 5-11 SECTION 3. The importance of this legislation and the 5-12 crowded condition of the calendars in both houses create an 5-13 emergency and an imperative public necessity that the 5-14 constitutional rule requiring bills to be read on three several 5-15 days in each house be suspended, and this rule is hereby suspended, 5-16 and that this Act take effect and be in force from and after its 5-17 passage, and it is so enacted.