By Thompson H.B. No. 1562
A BILL TO BE ENTITLED
1-1 AN ACT
1-2 relating to the control of health insurance fraud; providing
1-3 administrative penalties.
1-4 BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
1-5 SECTION 1. Article 1.10D, Insurance Code, is amended by
1-6 adding Section 3A to read as follows:
1-7 Sec. 3A. INSURER ANTIFRAUD INVESTIGATIVE REPORTS. (a) The
1-8 insurance fraud unit may receive, review, and investigate in a
1-9 timely manner insurer antifraud reports submitted under Subchapter
1-10 K, Chapter 3, of this code.
1-11 (b) The insurance fraud unit shall report annually in
1-12 writing to the commissioner the number of cases completed and any
1-13 recommendations for new regulatory and statutory responses to the
1-14 types of fraudulent activities encountered by the insurance fraud
1-15 unit.
1-16 SECTION 2. Section 6, Article 1.10D, Insurance Code, is
1-17 amended by amending Subsection (a) and adding Subsection (e) to
1-18 read as follows:
1-19 (a) A person acting without malice, fraudulent intent, or
1-20 bad faith is not subject to liability based on filing reports or
1-21 furnishing, orally or in writing, other information concerning
1-22 suspected, anticipated, or completed fraudulent insurance acts if
1-23 the reports or information are provided to:
1-24 (1) a law enforcement officer or an agent or employee
2-1 of a law enforcement officer;
2-2 (2) the National Association of Insurance
2-3 Commissioners, a state or federal governmental agency established
2-4 to detect and prevent fraudulent insurance acts or to regulate the
2-5 business of insurance, or an employee of that association or
2-6 governmental agency; [or]
2-7 (3) an authorized governmental agency or the
2-8 department; or
2-9 (4) a special investigative unit of an insurer,
2-10 including a person contracting to provide special investigative
2-11 unit services, or an employee of an insurer who is responsible for
2-12 the investigation of suspected fraudulent insurance acts.
2-13 (e) Information provided herein by an insurer to the
2-14 insurance fraud unit and/or an authorized governmental agency shall
2-15 not be subject to public disclosure. The information may be used
2-16 by the insurance fraud unit and/or governmental agency only for the
2-17 performance of its duties as described herein. An insurer must
2-18 exercise reasonable care concerning the accuracy of the information
2-19 conveyed to the insurance fraud unit, an authorized governmental
2-20 agency, other insurers, or other persons or entities.
2-21 SECTION 3. Chapter 3, Insurance Code, is amended by adding
2-22 Subchapter K to read as follows:
2-23 SUBCHAPTER K. INSURER ANTIFRAUD PROGRAMS
2-24 Art. 3.97-1. DEFINITIONS. In this subchapter:
2-25 (1) "Health care provider" means a person who
2-26 furnishes services under a license, certificate, registration, or
2-27 other authority issued by this state or another state to diagnose,
3-1 prevent, alleviate, or cure a human illness or injury.
3-2 (2) "Insurer" means:
3-3 (A) a health insurer, including a life, health,
3-4 and accident insurer, a health and accident insurer, a health
3-5 maintenance organization, or any other person operating under the
3-6 Texas Health Maintenance Organization Act (Chapter 20A, Vernon's
3-7 Texas Insurance Code) or under Chapter 3, 10, 20, 22, or 26 of this
3-8 code who is authorized to issue, issue for delivery, or deliver
3-9 policies, certificates, or contracts of insurance in this state;
3-10 (B) an approved nonprofit health corporation
3-11 that:
3-12 (i) is certified under Section 162.001(b),
3-13 Occupations Code; and
3-14 (ii) holds a certificate of authority
3-15 issued by the commissioner under Article 21.52F of this code; or
3-16 (C) an insurer authorized by the department to
3-17 write workers' compensation insurance in this state.
3-18 Art. 3.97-2. NOTICE OF PENALTY FOR FALSE OR FRAUDULENT
3-19 CLAIMS; DISPLAY ON FORMS. (a) If an insurer provides a form for a
3-20 person to use to make a claim against a policy issued by the
3-21 insurer or to give notice of a person's intent to make a claim
3-22 against a policy issued by the insurer, the insurer shall provide
3-23 on that form, in comparative prominence with the other content on
3-24 the form, a statement as follows: "Any person who knowingly
3-25 presents a false or fraudulent claim for the payment of a loss is
3-26 guilty of a crime and may be subject to fines and confinement in
3-27 state prison."
4-1 (b) This section does not apply to a claim made against a
4-2 policy issued by a reinsurer.
4-3 Art. 3.97-3. INSURER ANTIFRAUD PLANS. (a) An insurer shall
4-4 adopt an antifraud plan under this article. The insurer may
4-5 annually file that plan with the insurance fraud unit. The plan
4-6 must include:
4-7 (1) a description of the insurer's procedures for
4-8 detecting and investigating possible fraudulent insurance acts; and
4-9 (2) a description of the insurer's procedures for
4-10 reporting possible fraudulent insurance acts to the insurance fraud
4-11 unit.
4-12 (b) If an insurer participating in the STAR or STAR + Plus
4-13 Medicaid program, or the state child health plan under Chapter 62,
4-14 Health and Safety Code, has in place a fraud and abuse plan
4-15 approved by a health and human services agency, such plan shall be
4-16 deemed to meet the requirements of this subchapter. If such
4-17 insurer is required by law to report possible fraudulent insurance
4-18 acts to a health and human services agency and/or the Office of
4-19 Attorney General, such insurer shall not be required to also report
4-20 such acts to the insurance fraud unit.
4-21 (c) The health and human services agencies, the Office of
4-22 Attorney General, and the insurance fraud unit shall coordinate
4-23 enforcement efforts relating to acts covered by this subchapter
4-24 that occur in relation to the state Medicaid program or state child
4-25 health plan program.
4-26 SECTION 4. Subtitle A, Title 3, Occupations Code, is amended
4-27 by adding Chapter 105 to read as follows:
5-1 CHAPTER 105. UNPROFESSIONAL CONDUCT BY HEALTH CARE PROVIDER
5-2 Sec. 105.001. DEFINITION. In this chapter, "health care
5-3 provider" means a person who furnishes services under a license,
5-4 certificate, registration, or other authority issued by this state
5-5 or another state to diagnose, prevent, alleviate, or cure a human
5-6 illness or injury.
5-7 Sec. 105.002. UNPROFESSIONAL CONDUCT. (a) A health care
5-8 provider commits unprofessional conduct if the health care
5-9 provider, in connection with the provider's professional
5-10 activities:
5-11 (1) knowingly presents or causes to be presented a
5-12 false or fraudulent claim for the payment of a loss under an
5-13 insurance policy; or
5-14 (2) knowingly prepares, makes, or subscribes to any
5-15 writing, with intent to present or use the writing, or to allow it
5-16 to be presented or used, in support of a false or fraudulent claim
5-17 under an insurance policy.
5-18 (b) In addition to other provisions of civil or criminal
5-19 law, commission of unprofessional conduct under Subsection (a)
5-20 constitutes cause for the revocation or suspension of a provider's
5-21 license, permit, registration, certificate, or other authority or
5-22 other disciplinary action.
5-23 SECTION 5. (a) This Act takes effect September 1, 2001.
5-24 (b) The insurance fraud unit shall make the initial report
5-25 to the commissioner of insurance required under Section 3A(b),
5-26 Article 1.10D, Insurance Code, as added by this Act, not later than
5-27 January 1, 2003.