Texas 2021 - 87th Regular

Texas House Bill HB3235 Compare Versions

Only one version of the bill is available at this time.

Old	New	Differences
1	1	87R6862 MEW-F
2	2	By: Klick H.B. No. 3235
3	3
4	4
5	5	A BILL TO BE ENTITLED
6	6	AN ACT
7	7	relating to the investigation by the commissioner of insurance of
8	8	acts of health care fraud and the prosecution of health care fraud;
9	9	creating a criminal offense.
10	10	BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
11	11	SECTION 1. Section 701.102, Insurance Code, is amended to
12	12	read as follows:
13	13	Sec. 701.102. INVESTIGATION OF CERTAIN ACTS OF FRAUD. (a)
14	14	If the commissioner has reason to believe a person has engaged in,
15	15	is engaging in, has committed, or is about to commit a fraudulent
16	16	insurance act, the commissioner may conduct any investigation
17	17	necessary inside or outside this state to:
18	18	(1) determine whether the act occurred; or
19	19	(2) aid in enforcing laws relating to fraudulent
20	20	insurance acts, including by providing technical or litigation
21	21	assistance to other governmental agencies.
22	22	(b) In conducting investigations under Subsection (a), the
23	23	commissioner shall give priority to investigating alleged conduct
24	24	constituting an offense under Section 35A.02(a-1), Penal Code.
25	25	SECTION 2. Section 35A.01, Penal Code, is amended by adding
26	26	Subdivisions (2-a) and (2-b) and amending Subdivision (9) to read
27	27	as follows:
28	28	(2-a) "Health benefit claim" means a written or
29	29	electronically submitted request or demand that:
30	30	(A) is submitted by a person who supplies or
31	31	purports to supply a service or product to an individual covered by
32	32	a health benefit plan or that person's agent and identifies a
33	33	service or product provided or purported to have been provided to
34	34	the covered individual as reimbursable by a health benefit plan
35	35	issuer, without regard to whether the money that is requested or
36	36	demanded is paid and without regard to whether the individual was
37	37	eligible for benefits under the health benefit plan; or
38	38	(B) states the income earned or expense incurred
39	39	by a person in providing a service or product to an individual
40	40	covered by a health benefit plan and is used to determine a rate of
41	41	payment by a health benefit plan issuer.
42	42	(2-b) "Health benefit plan issuer" means a person who is
43	43	authorized or otherwise permitted by law to arrange for or provide
44	44	health insurance or health benefits, including a health maintenance
45	45	organization.
46	46	(9) "Service" includes care or treatment of a health
47	47	care recipient or an individual covered by a health benefit plan, as
48	48	applicable.
49	49	SECTION 3. Section 35A.02, Penal Code, is amended by adding
50	50	Subsection (a-1) and amending Subsections (b) and (d) to read as
51	51	follows:
52	52	(a-1) A person commits an offense if the person knowingly
53	53	makes or causes to be made a health benefit claim to a health
54	54	benefit plan issuer for:
55	55	(1) a service or product that has not been approved or
56	56	acquiesced in by a treating physician or health care practitioner;
57	57	(2) a service or product that is substantially
58	58	inadequate or inappropriate when compared to generally recognized
59	59	standards within the particular discipline or within the health
60	60	care industry; or
61	61	(3) a product that has been adulterated, debased,
62	62	mislabeled, or that is otherwise inappropriate.
63	63	(b) An offense under this section is:
64	64	(1) a Class C misdemeanor if the amount of any payment
65	65	or the value of any monetary or in-kind benefit provided or claim
66	66	for payment made under a health care program or by a health benefit
67	67	plan issuer, as applicable, directly or indirectly, as a result of
68	68	the conduct is less than $100;
69	69	(2) a Class B misdemeanor if the amount of any payment
70	70	or the value of any monetary or in-kind benefit provided or claim
71	71	for payment made under a health care program or by a health benefit
72	72	plan issuer, as applicable, directly or indirectly, as a result of
73	73	the conduct is $100 or more but less than $750;
74	74	(3) a Class A misdemeanor if the amount of any payment
75	75	or the value of any monetary or in-kind benefit provided or claim
76	76	for payment made under a health care program or by a health benefit
77	77	plan issuer, as applicable, directly or indirectly, as a result of
78	78	the conduct is $750 or more but less than $2,500;
79	79	(4) a state jail felony if:
80	80	(A) the amount of any payment or the value of any
81	81	monetary or in-kind benefit provided or claim for payment made
82	82	under a health care program or by a health benefit plan issuer, as
83	83	applicable, directly or indirectly, as a result of the conduct is
84	84	$2,500 or more but less than $30,000;
85	85	(B) the offense is committed under Subsection
86	86	(a)(11); or
87	87	(C) it is shown on the trial of the offense that
88	88	the amount of the payment or value of the benefit described by this
89	89	subsection cannot be reasonably ascertained;
90	90	(5) a felony of the third degree if:
91	91	(A) the amount of any payment or the value of any
92	92	monetary or in-kind benefit provided or claim for payment made
93	93	under a health care program or by a health benefit plan issuer, as
94	94	applicable, directly or indirectly, as a result of the conduct is
95	95	$30,000 or more but less than $150,000; or
96	96	(B) it is shown on the trial of the offense that
97	97	the defendant submitted more than 25 but fewer than 50 fraudulent
98	98	claims under a health care program or to a health benefit plan
99	99	issuer, as applicable, and the submission of each claim constitutes
100	100	conduct prohibited by Subsection (a);
101	101	(6) a felony of the second degree if:
102	102	(A) the amount of any payment or the value of any
103	103	monetary or in-kind benefit provided or claim for payment made
104	104	under a health care program or by a health benefit plan issuer, as
105	105	applicable, directly or indirectly, as a result of the conduct is
106	106	$150,000 or more but less than $300,000; or
107	107	(B) it is shown on the trial of the offense that
108	108	the defendant submitted 50 or more fraudulent claims under a health
109	109	care program or to a health benefit plan issuer, as applicable, and
110	110	the submission of each claim constitutes conduct prohibited by
111	111	Subsection (a); or
112	112	(7) a felony of the first degree if the amount of any
113	113	payment or the value of any monetary or in-kind benefit provided or
114	114	claim for payment made under a health care program or by a health
115	115	benefit plan issuer, as applicable, directly or indirectly, as a
116	116	result of the conduct is $300,000 or more.
117	117	(d) When multiple payments or monetary or in-kind benefits
118	118	are provided under one or more health care programs or by one or
119	119	more health benefit plan issuers as a result of one scheme or
120	120	continuing course of conduct, the conduct may be considered as one
121	121	offense and the amounts of the payments or monetary or in-kind
122	122	benefits aggregated in determining the grade of the offense.
123	123	SECTION 4. The change in law made by this Act applies only
124	124	to an offense committed on or after the effective date of this Act.
125	125	An offense committed before the effective date of this Act is
126	126	governed by the law in effect on the date the offense was committed,
127	127	and the former law is continued in effect for that purpose. For
128	128	purposes of this section, an offense was committed before the
129	129	effective date of this Act if any element of the offense occurred
130	130	before that date.
131	131	SECTION 5. This Act takes effect September 1, 2021.