Texas Administrative Code
Title 28 - INSURANCE
Part 2 - TEXAS DEPARTMENT OF INSURANCE, DIVISION OF WORKERS' COMPENSATION
Chapter 180 - MONITORING AND ENFORCEMENT
Subchapter B - MEDICAL BENEFIT REGULATION
Section 180.24 - Financial Disclosure
Universal Citation: 28 TX Admin Code ยง 180.24
Current through Reg. 49, No. 38; September 20, 2024
(a) Definitions. The following words and terms when used in this section shall have the following meanings unless the context clearly indicates otherwise.
(1) Compensation arrangement--Any arrangement
involving any remuneration between a health care practitioner (or a member of a
health care practitioner's immediate family) and a health care
provider.
(2) Financial interest
means:
(A) an interest of a health care
practitioner, including an interest of the health care provider who employs the
health care practitioner, or an interest of an immediate family member of the
health care practitioner, which constitutes a direct or indirect ownership or
investment interest in a health care provider; or
(B) a direct or indirect compensation
arrangement between the health care practitioner, the health care provider who
employs the referring health care practitioner, or an immediate family member
of the health care practitioner and a health care provider.
(3) Immediate family
member--Immediate family member or member of a doctor's immediate family means
husband or wife; birth or adoptive parent, child, or sibling; stepparent,
stepchild, stepbrother, or stepsister; father-in-law, mother-in-law,
son-in-law, daughter-in-law, brother-in-law, or sister-in-law; grandparent or
grandchild; and spouse of a grandparent or grandchild.
(b) Submission of Financial Disclosure Information to the division.
(1) If a health
care practitioner refers an injured employee to another health care provider in
which the health care practitioner, or the health care provider that employs
the health care practitioner, has a financial interest, the health care
practitioner shall file a disclosure with the division within 30 days of the
date the first referral is made unless the disclosure was previously made. This
annual disclosure shall be filed for each health care provider to whom an
injured employee is referred and shall include the information in paragraph (2)
of this subsection.
(2) The health
care practitioner's disclosures in paragraph (1) of this subsection shall at a
minimum include:
(A) the disclosing health
care practitioner's name, business address, federal tax identification number,
professional license number, and any other unique identification
number;
(B) the name(s), business
address(es), federal tax identification number(s), professional license
number(s), and any other unique identification number of the health care
provider(s) in which the disclosing health care practitioner has a financial
interest as defined in subsection (a)(2) of this section; and
(C) the nature of the financial interest
including, but not limited to, percentage of ownership, type of ownership
(e.g., direct or indirect, equity, mortgage), type of compensation arrangement
(e.g., salary, contractual arrangement, stock as part of a salary payment) and
the entity with the ownership (disclosing health care practitioner, the health
care provider who employs the health care practitioner, or an immediate family
member of the health care practitioner).
(c) Failure to disclose. In addition to any sanctions provided by the Act and rules, failure to disclose a financial interest by a health care provider is an administrative violation and is subject to a penalty of forfeiture of the right to reimbursement for any services rendered on the claim during the period of noncompliance, regardless of whether the circumstances of the services themselves were subject to disclosure, and regardless of whether the services were medically necessary.
(1) Limitations on billing. A health care
practitioner who rendered services on a claim during a period in which the
practitioner was out of compliance with the disclosure requirements under this
section for that claim, regardless of whether the circumstances of the services
themselves were subject to disclosure, shall not present or cause to be
presented a claim or bill to any individual, third party payer, or other entity
for those services (regardless of whether the services were medically
necessary).
(2) Refunds. If a
health care practitioner collects any amounts that were billed for services on
a claim provided during a period in which the practitioner was in noncompliance
with the disclosure requirements of this section for that claim, regardless of
whether the circumstances of the services themselves were subject to
disclosure, the practitioner shall be liable to the individual or entity for,
and shall timely refund, any amounts collected (regardless of whether the
services were medically necessary).
(3) Rebuttable Presumption. A referral for
services to a health care provider by a health care practitioner under
circumstances which required a disclosure under this section, but which was not
timely disclosed as required, creates a rebuttable presumption that the
services were not medically necessary unless one of the statutory and
regulatory exceptions that apply to referrals in Title 42, United States Code
§1395nn(b)-(e) applies to the referral in question. Whenever one of these
exceptions is revised and effective, the revised exception shall be effective
for referrals made on or after the effective date of the revision.
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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