2023 Texas Statutes › Human Resources Code › Title 2 - Human Services and Protective Services in General › Subtitle C - Assistance Programs › Chapter 36 - Health Care Program Fraud Prevention › Subchapter A. General Provisions › Section 36.002. Unlawful Acts

Sec. 36.002.  UNLAWFUL ACTS.  A person commits an unlawful act if the person:
(1)  knowingly makes or causes to be made a false statement or misrepresentation of a material fact to permit a person to receive a benefit or payment under a health care program that is not authorized or that is greater than the benefit or payment that is authorized;
(2)  knowingly conceals or fails to disclose information that permits a person to receive a benefit or payment under a health care program that is not authorized or that is greater than the benefit or payment that is authorized;
(3)  knowingly applies for and receives a benefit or payment on behalf of another person under a health care program and converts any part of the benefit or payment to a use other than for the benefit of the person on whose behalf it was received;
(4)  knowingly makes, causes to be made, induces, or seeks to induce the making of a false statement or misrepresentation of material fact concerning:
(A)  the conditions or operation of a facility in order that the facility may qualify for certification or recertification required by a health care program, including certification or recertification as:
(i)  a hospital;
(ii)  a nursing facility or skilled nursing facility;
(iii)  a hospice;
(iv)  an ICF-IID;
(v)  an assisted living facility; or
(vi)  a home health agency; or
(B)  information required to be provided by a federal or state law, rule, regulation, or provider agreement pertaining to a health care program;
(5)  except as authorized under a health care program, knowingly pays, charges, solicits, accepts, or receives, in addition to an amount paid under the program, a gift, money, a donation, or other consideration as a condition to the provision of a service or product or the continued provision of a service or product if the cost of the service or product is paid for, in whole or in part, under the program;
(6)  knowingly presents or causes to be presented a claim for payment under a health care program for a product provided or a service rendered by a person who:
(A)  is not licensed to provide the product or render the service, if a license is required; or
(B)  is not licensed in the manner claimed;
(7)  knowingly makes or causes to be made a claim under a health care program for:
(A)  a service or product that has not been approved or acquiesced in by a treating physician or health care practitioner;
(B)  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
(C)  a product that has been adulterated, debased, mislabeled, or that is otherwise inappropriate;
(8)  makes a claim under a health care program and knowingly fails to indicate the type of license and the identification number of the licensed health care provider who actually provided the service;
(9)  conspires to commit a violation of Subdivision (1), (2), (3), (4), (5), (6), (7), (8), (10), (11), (12), or (13);
(10)  is a managed care organization that contracts with the commission or other state agency to provide or arrange to provide health care benefits or services to individuals eligible under a health care program and knowingly:
(A)  fails to provide to an individual a health care benefit or service that the organization is required to provide under the contract;
(B)  fails to provide to the commission or appropriate state agency information required to be provided by law, commission or agency rule, or contractual provision; or
(C)  engages in a fraudulent activity in connection with the enrollment of an individual eligible under the program in the organization's managed care plan or in connection with marketing the organization's services to an individual eligible under the program;
(11)  knowingly obstructs an investigation by the attorney general of an alleged unlawful act under this section;
(12)  knowingly makes, uses, or causes the making or use of a false record or statement material to an obligation to pay or transmit money or property to this state under a health care program, or knowingly conceals or knowingly and improperly avoids or decreases an obligation to pay or transmit money or property to this state under a health care program; or
(13)  knowingly engages in conduct that constitutes a violation under Section 32.039(b).
Added by Acts 1995, 74th Leg., ch. 824, Sec. 1, eff. Sept. 1, 1995.  Amended by Acts 1997, 75th Leg., ch. 1153, Sec. 4.03, eff. Sept. 1, 1997;  Acts 1999, 76th Leg., ch. 233, Sec. 4, eff. Sept. 1, 1999.
Amended by:
Acts 2005, 79th Leg., Ch. 806 (S.B. 563), Sec. 3, eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch. 78 (H.B. 889), Sec. 1, eff. September 1, 2007.
Acts 2011, 82nd Leg., R.S., Ch. 398 (S.B. 544), Sec. 2, eff. September 1, 2011.
Acts 2013, 83rd Leg., R.S., Ch. 572 (S.B. 746), Sec. 1, eff. September 1, 2013.
Acts 2015, 84th Leg., R.S., Ch. 1 (S.B. 219), Sec. 4.180, eff. April 2, 2015.
Acts 2023, 88th Leg., R.S., Ch. 273 (S.B. 745), Sec. 4, eff. September 1, 2023.