CHAPTER 105. UNPROFESSIONAL CONDUCT BY HEALTH CARE PROVIDER

OCCUPATIONS CODE

TITLE 3. HEALTH PROFESSIONS

SUBTITLE A. PROVISIONS APPLYING TO HEALTH PROFESSIONS GENERALLY

CHAPTER 105. UNPROFESSIONAL CONDUCT BY HEALTH CARE PROVIDER

Sec. 105.001. DEFINITION. In this chapter, "health care

provider" means a person who furnishes services under a license,

certificate, registration, or other authority issued by this

state or another state to diagnose, prevent, alleviate, or cure a

human illness or injury.

Added by Acts 2001, 77th Leg., ch. 1033, Sec. 4, eff. Sept. 1,

2001.

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, Sec. 1, eff. September 1, 2005.