By Moncrief S.B. No. 892
77R2978 MXM-D
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(a), Article 1.10D, Insurance Code, is
1-17 amended to read as follows:
1-18 (a) A person acting without malice, fraudulent intent, or
1-19 bad faith is not subject to liability based on filing reports or
1-20 furnishing, orally or in writing, other information concerning
1-21 suspected, anticipated, or completed fraudulent insurance acts if
1-22 the reports or information are provided to:
1-23 (1) a law enforcement officer or an agent or employee
1-24 of a law enforcement officer;
2-1 (2) the National Association of Insurance
2-2 Commissioners, a state or federal governmental agency established
2-3 to detect and prevent fraudulent insurance acts or to regulate the
2-4 business of insurance, or an employee of that association or
2-5 governmental agency; [or]
2-6 (3) an authorized governmental agency or the
2-7 department; or
2-8 (4) an individual employed by or acting on behalf of
2-9 an insurer to detect and prevent fraudulent insurance acts.
2-10 SECTION 3. Chapter 3, Insurance Code, is amended by adding
2-11 Subchapter K to read as follows:
2-12 SUBCHAPTER K. INSURER ANTIFRAUD PROGRAMS
2-13 Art. 3.97-1. DEFINITIONS. In this subchapter:
2-14 (1) "Health care provider" means a person who
2-15 furnishes services under a license, certificate, registration, or
2-16 other authority issued by this state or another state to diagnose,
2-17 prevent, alleviate, or cure a human illness or injury.
2-18 (2) "Insurer" means:
2-19 (A) a health insurer, including a life, health,
2-20 and accident insurer, a health and accident insurer, a health
2-21 maintenance organization, or any other person operating under the
2-22 Texas Health Maintenance Organization Act (Chapter 20A, Vernon's
2-23 Texas Insurance Code) or under Chapter 3, 10, 20, 22, or 26 of this
2-24 code who is authorized to issue, issue for delivery, or deliver
2-25 policies, certificates, or contracts of insurance in this state;
2-26 (B) an approved nonprofit health corporation
2-27 that:
3-1 (i) is certified under Section 162.001(b),
3-2 Occupations Code; and
3-3 (ii) holds a certificate of authority
3-4 issued by the commissioner under Article 21.52F of this code; or
3-5 (C) an insurer authorized by the department to
3-6 write workers' compensation insurance in this state.
3-7 Art. 3.97-2. NOTICE OF PENALTY FOR FALSE OR FRAUDULENT
3-8 CLAIMS; DISPLAY ON FORMS. (a) If an insurer provides a form for a
3-9 person to use to make a claim against a policy issued by the
3-10 insurer or to give notice of a person's intent to make a claim
3-11 against a policy issued by the insurer, the insurer shall provide
3-12 on that form, in comparative prominence with the other content on
3-13 the form, a statement as follows: "Any person who knowingly
3-14 presents a false or fraudulent claim for the payment of a loss is
3-15 guilty of a crime and may be subject to fines and confinement in
3-16 state prison."
3-17 (b) This section does not apply to a claim made against a
3-18 policy issued by a reinsurer.
3-19 Art. 3.97-3. INSURER ANTIFRAUD PLANS. An insurer shall
3-20 adopt an antifraud plan under this article. The insurer may
3-21 annually file that plan with the insurance fraud unit. The plan
3-22 must include:
3-23 (1) a description of the insurer's procedures for
3-24 detecting and investigating possible fraudulent insurance acts; and
3-25 (2) a description of the insurer's procedures for
3-26 reporting possible fraudulent insurance acts to the insurance fraud
3-27 unit.
4-1 SECTION 4. Subtitle A, Title 3, Occupations Code, is amended
4-2 by adding Chapter 105 to read as follows:
4-3 CHAPTER 105. UNPROFESSIONAL CONDUCT BY HEALTH CARE PROVIDER
4-4 Sec. 105.001. DEFINITION. In this chapter, "health care
4-5 provider" means a person who furnishes services under a license,
4-6 certificate, registration, or other authority issued by this state
4-7 or another state to diagnose, prevent, alleviate, or cure a human
4-8 illness or injury.
4-9 Sec. 105.002. UNPROFESSIONAL CONDUCT. (a) A health care
4-10 provider commits unprofessional conduct if the health care
4-11 provider, in connection with the provider's professional
4-12 activities:
4-13 (1) knowingly presents or causes to be presented a
4-14 false or fraudulent claim for the payment of a loss under an
4-15 insurance policy; or
4-16 (2) knowingly prepares, makes, or subscribes to any
4-17 writing, with intent to present or use the writing, or to allow it
4-18 to be presented or used, in support of a false or fraudulent claim
4-19 under an insurance policy.
4-20 (b) In addition to other provisions of civil or criminal
4-21 law, commission of unprofessional conduct under Subsection (a)
4-22 constitutes cause for the revocation or suspension of a provider's
4-23 license, permit, registration, certificate, or other authority or
4-24 other disciplinary action.
4-25 SECTION 5. (a) This Act takes effect September 1, 2001.
4-26 (b) The insurance fraud unit shall make the initial report
4-27 to the commissioner of insurance required under Section 3A(b),
5-1 Article 1.10D, Insurance Code, as added by this Act, not later than
5-2 January 1, 2003.