Texas Administrative Code
Title 22 - EXAMINING BOARDS
Part 9 - TEXAS MEDICAL BOARD
Chapter 187 - PROCEDURAL RULES
Subchapter J - PROCEDURES RELATED TO OUT-OF-NETWORK HEALTH BENEFIT CLAIM DISPUTE RESOLUTION
Section 187.88 - Complaint Process and Resolution
Universal Citation: 22 TX Admin Code ยง 187.88
Current through Reg. 49, No. 38; September 20, 2024
(a) A complaint relating to a mediation may be filed by a mediator with the Board against a facility-based physician for bad faith mediation. Conduct constituting bad faith mediation includes:
(1) failing to participate in a
mediation;
(2) failing to provide
information the mediator believes is necessary to facilitate an agreement;
or
(3) failing to designate a
representative participating in the mediation with full authority to enter into
any mediated agreement.
(b) If the enrollee is not satisfied with a mediated agreement, the enrollee may file a complaint with the Board against a facility-based physician for improper billing reached under Chapter 1467 of the Insurance Code.
(c) Investigations.
(1) All complaints shall be investigated
pursuant to Chapter 179 of this title (relating to Investigations) and referred
to an informal settlement conference if appropriate.
(2) In accordance with §
311.0025 of the
Health and Safety Code, the Board shall not open investigations relating to
complaints of a single instance of improper billing, but shall open
investigations on facility-based physicians who are alleged to have engaged in
improper billing in multiple instances.
(d) Penalties.
(1) Bad Faith Mediation. Except for good
cause shown, on a report of a mediator and appropriate proof of bad faith
mediation, the Board shall impose an administrative penalty.
(2) Improper Billing. If the Board determines
that a facility-based physician has engaged in improper billing practices, the
Board shall impose sanctions consistent with §
190.14
of this title (relating to Disciplinary Sanction Guidelines).
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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