87R6862 MEW-F
By: Klick H.B. No. 3235
A BILL TO BE ENTITLED
AN ACT
relating to the investigation by the commissioner of insurance of
acts of health care fraud and the prosecution of health care fraud;
creating a criminal offense.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:
SECTION 1. Section 701.102, Insurance Code, is amended to
read as follows:
Sec. 701.102. INVESTIGATION OF CERTAIN ACTS OF FRAUD. (a)
If the commissioner has reason to believe a person has engaged in,
is engaging in, has committed, or is about to commit a fraudulent
insurance act, the commissioner may conduct any investigation
necessary inside or outside this state to:
(1) determine whether the act occurred; or
(2) aid in enforcing laws relating to fraudulent
insurance acts, including by providing technical or litigation
assistance to other governmental agencies.
(b) In conducting investigations under Subsection (a), the
commissioner shall give priority to investigating alleged conduct
constituting an offense under Section 35A.02(a-1), Penal Code.
SECTION 2. Section 35A.01, Penal Code, is amended by adding
Subdivisions (2-a) and (2-b) and amending Subdivision (9) to read
as follows:
(2-a) "Health benefit claim" means a written or
electronically submitted request or demand that:
(A) is submitted by a person who supplies or
purports to supply a service or product to an individual covered by
a health benefit plan or that person's agent and identifies a
service or product provided or purported to have been provided to
the covered individual as reimbursable by a health benefit plan
issuer, without regard to whether the money that is requested or
demanded is paid and without regard to whether the individual was
eligible for benefits under the health benefit plan; or
(B) states the income earned or expense incurred
by a person in providing a service or product to an individual
covered by a health benefit plan and is used to determine a rate of
payment by a health benefit plan issuer.
(2-b) "Health benefit plan issuer" means a person who is
authorized or otherwise permitted by law to arrange for or provide
health insurance or health benefits, including a health maintenance
organization.
(9) "Service" includes care or treatment of a health
care recipient or an individual covered by a health benefit plan, as
applicable.
SECTION 3. Section 35A.02, Penal Code, is amended by adding
Subsection (a-1) and amending Subsections (b) and (d) to read as
follows:
(a-1) A person commits an offense if the person knowingly
makes or causes to be made a health benefit claim to a health
benefit plan issuer for:
(1) a service or product that has not been approved or
acquiesced in by a treating physician or health care practitioner;
(2) a service or product that is substantially
inadequate or inappropriate when compared to generally recognized
standards within the particular discipline or within the health
care industry; or
(3) a product that has been adulterated, debased,
mislabeled, or that is otherwise inappropriate.
(b) An offense under this section is:
(1) a Class C misdemeanor if the amount of any payment
or the value of any monetary or in-kind benefit provided or claim
for payment made under a health care program or by a health benefit
plan issuer, as applicable, directly or indirectly, as a result of
the conduct is less than $100;
(2) a Class B misdemeanor if the amount of any payment
or the value of any monetary or in-kind benefit provided or claim
for payment made under a health care program or by a health benefit
plan issuer, as applicable, directly or indirectly, as a result of
the conduct is $100 or more but less than $750;
(3) a Class A misdemeanor if the amount of any payment
or the value of any monetary or in-kind benefit provided or claim
for payment made under a health care program or by a health benefit
plan issuer, as applicable, directly or indirectly, as a result of
the conduct is $750 or more but less than $2,500;
(4) a state jail felony if:
(A) the amount of any payment or the value of any
monetary or in-kind benefit provided or claim for payment made
under a health care program or by a health benefit plan issuer, as
applicable, directly or indirectly, as a result of the conduct is
$2,500 or more but less than $30,000;
(B) the offense is committed under Subsection
(a)(11); or
(C) it is shown on the trial of the offense that
the amount of the payment or value of the benefit described by this
subsection cannot be reasonably ascertained;
(5) a felony of the third degree if:
(A) the amount of any payment or the value of any
monetary or in-kind benefit provided or claim for payment made
under a health care program or by a health benefit plan issuer, as
applicable, directly or indirectly, as a result of the conduct is
$30,000 or more but less than $150,000; or
(B) it is shown on the trial of the offense that
the defendant submitted more than 25 but fewer than 50 fraudulent
claims under a health care program or to a health benefit plan
issuer, as applicable, and the submission of each claim constitutes
conduct prohibited by Subsection (a);
(6) a felony of the second degree if:
(A) the amount of any payment or the value of any
monetary or in-kind benefit provided or claim for payment made
under a health care program or by a health benefit plan issuer, as
applicable, directly or indirectly, as a result of the conduct is
$150,000 or more but less than $300,000; or
(B) it is shown on the trial of the offense that
the defendant submitted 50 or more fraudulent claims under a health
care program or to a health benefit plan issuer, as applicable, and
the submission of each claim constitutes conduct prohibited by
Subsection (a); or
(7) a felony of the first degree if the amount of any
payment or the value of any monetary or in-kind benefit provided or
claim for payment made under a health care program or by a health
benefit plan issuer, as applicable, directly or indirectly, as a
result of the conduct is $300,000 or more.
(d) When multiple payments or monetary or in-kind benefits
are provided under one or more health care programs or by one or
more health benefit plan issuers as a result of one scheme or
continuing course of conduct, the conduct may be considered as one
offense and the amounts of the payments or monetary or in-kind
benefits aggregated in determining the grade of the offense.
SECTION 4. The change in law made by this Act applies only
to an offense committed on or after the effective date of this Act.
An offense committed before the effective date of this Act is
governed by the law in effect on the date the offense was committed,
and the former law is continued in effect for that purpose. For
purposes of this section, an offense was committed before the
effective date of this Act if any element of the offense occurred
before that date.
SECTION 5. This Act takes effect September 1, 2021.