Current through Reg. 49, No. 38; September 20, 2024
(a) Pursuant to Labor Code §
415.0036,
offering, paying, soliciting, or receiving an improper inducement relating to
the delivery of benefits to an injured employee is prohibited. Improper
attempts to influence the delivery of benefits to an injured employee,
including the making of improper threats. This section applies to all system
participants in the workers' compensation system who have authority under Labor
Code, Title 5 to request the performance of a service affecting the delivery of
benefits to an injured employee or who actually performs such a service,
including peer reviews, performance of designated doctor examinations,
performance of required medical examinations, or case management.
(b) The following specific acts will be
deemed to be an improper inducement, attempt to influence or threat:
(1) Soliciting or receiving any remuneration
(including, but not limited to, any kickback, bribe, or rebate) in return for
referring an injured employee to a person (either the person soliciting or
receiving the inducement or another person):
(A) for the furnishing or arranging for the
furnishing of any item, treatment, or service constituting a medical benefit
for which payment may be made in whole or in part under Labor Code, Title 5 or
rules; or
(B) in return for
purchasing, leasing, ordering, or arranging for or recommending purchasing,
leasing, or ordering any good, facility, service, treatment or item
constituting a medical benefit for which payment may be made in whole or in
part under Labor Code, Title 5 or rules.
(2) Offering or paying any remuneration
(including, but not limited to, any kickback, bribe, or rebate) in return for
referring an injured employee to a person (either the person offering or paying
the inducement or another person):
(A) for the
furnishing or arranging for the furnishing of any item, treatment or service
constituting a medical benefit for which payment may be made in whole or in
part under the Labor Code, Title 5 or rules; or
(B) in return for purchasing, leasing,
ordering, or arranging for or recommending purchasing, leasing, or ordering any
good, facility, service, treatment, or item constituting a medical benefit for
which payment may be made in whole or in part under Labor Code, Title 5 or
rules.
(3) Providing any
financial incentive or promising or threatening to provide injured employee
evaluation reports or other medical opinions that could enhance or reduce the
injured employee's income benefits or affect the injured employee's work
release status as an inducement to have the injured employee treat with or be
evaluated by the health care provider or comply with the health care provider's
proposed treatment.
(4) Offering or
soliciting an inducement in return for selecting a particular health care
provider for the furnishing or arranging for the furnishing of any item,
treatment, or service (including purchasing or leasing) for which payment may
be made in whole or in part under Labor Code, Title 5 or rules; or offering or
soliciting an inducement which may reasonably tend to cause a particular health
care provider to be selected (excluding a convenience necessary to allow for
the provision of health care, such as transportation to and from the health
care provider's facility, translator services related to evaluation and
treatment, providing claim filing forms or information on rights and
responsibilities under the Labor Code, Title 5 and rules, if generally
available to all patients). Such inducement is improper whether offered
directly or indirectly, overtly or covertly, in cash or in kind.
(5) Making, presenting, filing, or
threatening to make, present, or file any frivolous claim or assertion against
a system participant, medical peer reviewer, or any other person performing
duties arising under Labor Code, Title 5 or rules, with the division or any
licensing, certifying, regulatory, or investigatory body.
(6) Making or causing to be made a threat
against life, safety, or property directed to a system participant related to
their performance of duties arising under Labor Code, Title 5 or
rules.
(c) The
exceptions that apply to subsection (b)(1) and (2) of this section are those
that apply to analogous provisions in Title 42, United States Code
§1320a-7b(3). The exceptions shall apply to subsection (b)(1) and (2) of
this section.
(d) A violation of
applicable federal standards that prohibit the payment or acceptance of payment
in exchange for health care referrals relating to fraud, abuse, and
antikickbacks is an administrative violation.
