A health care provider may not knowingly submit or help submit false insurance claims, false supporting writings, or direct a patient to a niche hospital where the provider has a financial interest unless the provider gives the required written disclosure and alternative-facility notice.
Sec. 105.002. UNPROFESSIONAL CONDUCT. (a) A health care provider commits unprofessional conduct if the health care provider, in connection with the provider's professional activities: (1) knowingly presents or causes to be presented a false or fraudulent claim for the payment of a loss under an insurance policy; (2) knowingly prepares, makes, or subscribes to any writing, with intent to present or use the writing, or to allow it to be presented or used, in support of a false or fraudulent claim under an insurance policy; or (3) knowingly directs or requires a patient to obtain health care goods or services from a niche hospital in which the health care provider or an immediate family member of the provider has a financial interest, unless the provider: (A) discloses to the patient, in writing, that the provider or the provider's family member has a financial interest in the niche hospital; and (B) informs the patient that the patient has the option of using an alternative health care facility. (b) In addition to other provisions of civil or criminal law, commission of unprofessional conduct under Subsection (a) constitutes cause for the revocation or suspension of a provider's license, permit, registration, certificate, or other authority or other disciplinary action. (c) Subsection (a)(3) does not apply to a financial interest in publicly available shares of a registered investment company, such as a mutual fund, that owns publicly traded equity securities or debt obligations issued by a niche hospital or an entity that owns the niche hospital. (d) In this section: (1) "Diagnosis-related group" means the classification system mandated by Medicare regulations for reimbursement purposes that groups patients according to principal diagnosis, presence of a surgical procedure, age, presence or absence of significant complications, and other relevant criteria. (2) "Niche hospital" means a hospital that: (A) classifies at least two-thirds of the hospital's Medicare patients or, if data is available, all patients: (i) in not more than two major diagnosis-related groups; or (ii) in surgical diagnosis-related groups; (B) specializes in one or more of the following areas: (i) cardiac; (ii) orthopedics; (iii) surgery; or (iv) women's health; and (C) is not: (i) a public hospital; (ii) a hospital for which the majority of inpatient claims are for major diagnosis-related groups relating to rehabilitation, psychiatry, alcohol and drug treatment, or children or newborns; or (iii) a hospital with fewer than 10 claims per bed per year. Added by Acts 2001, 77th Leg., ch. 1033, Sec. 4, eff. Sept. 1, 2001. Amended by: Acts 2005, 79th Leg., Ch. 836 (S.B. 872), Sec. 1, eff. September 1, 2005.