(a) The division may impose sanctions on any system
participant if that system participant commits an administrative violation.
(b) The division may impose the following sanctions
against a doctor or insurance carrier for any reason listed in Labor
Code §408.0231(c) or any other criteria the commissioner considers
relevant.
(c) In addition to a penalty or the other sanctions
that may be imposed in accordance with other applicable provisions
of the Act, the division may also impose the following sanctions pursuant
to Labor Code §415.023(b) against an insurance carrier or its
representative, a health care provider, or a representative of an
injured employee or legal beneficiary if any of those parties commit
an administrative violation as a matter of practice, meaning a repeated
violation of the Act or a rule, order, or decision of the commissioner:
(1) a reduction or denial of fees;
(2) public or private reprimand by the commissioner;
(3) suspension from practice before the division;
(4) restriction, suspension, or revocation of the right
to receive reimbursement under the Act; and
(5) referral and petition to the appropriate licensing
authority for appropriate disciplinary action, including the restriction,
suspension, or revocation of the person's license.
(d) In addition to, or in lieu of, the sanctions in
subsections (b) and (c) of this section, the division may impose any
other sanction or remedy allowed under the Act or division rules,
including but not limited to assessing an administrative penalty of
up to $25,000 per violation against a person who commits an administrative
violation.
(e) When determining which sanction to impose against
a system participant and the severity of that sanction, the division
shall consider the factors listed in Labor Code §415.021(c) and
other matters that justice may require, including but not limited
to:
(1) Performance Based Oversight (PBO) assessment;
(2) the promptness and earnestness of actions to prevent
future violations;
(3) self-report of the violation;
(4) the size of the company or practice;
(5) the effect of a sanction on the availability of
health care; and
(6) evidence of heightened awareness of the legal duty
to comply with the Act and division rules.
(f) When determining which sanction to impose against
a system participant and the severity of that sanction in claims where
the insurance carrier provided notice under Labor Code §409.021(a-3),
(Notice of Continuing Investigation), the division shall consider
the factors listed in Labor Code §415.021(c-2).
(g) In an investigation where both an administrative
violation and a criminal prosecution are possible, the division may,
at its discretion, postpone action on the administrative violation
until the related criminal prosecution is completed.
(h) As an alternative to imposing a sanction such as
an administrative penalty on a charged system participant, the division
may, at its discretion, provide formal notice of the violation through
a Warning Letter. A Warning Letter shall:
(1) include a summary of the duty that the division
believes that the charged system participant failed to fulfill or
timely fulfill;
(2) identify the facts that establish that a violation
occurred; and
(3) inform the charged system participant that subsequent
noncompliance of the same sort may be deemed to be a repeated administrative
violation or matter of practice, any of which will be subject to sanction.
(i) The division may enter into a consent order with
the system participant if the division and the system participant
have communicated regarding:
(1) the relevant statute or rule violated;
(2) the facts establishing that the administrative
violation occurred; and
(3) the appropriateness of the proposed sanction, including
how the division considered the factors under Labor Code §415.021(c)
and (c-2) and subsection (e) of this section in determining the proposed
sanction.
(j) A consent order may be entered into before or after
issuance of an NOV under §180.8 of this title (relating to Notices
of Violation; Notices of Hearing; Default Judgments). Consent orders
must include:
(1) a description of which factors under Labor Code §415.021(c)
and (c-2) and subsection (e) of this section the division considered
aggravating or mitigating when determining the proposed sanctions;
and
(2) a statement that the system participant acknowledges:
(A) the division and the system participant communicated
regarding the information listed in subsection (h)(1)-(3) of this
section; and
(B) the division considered the factors under Labor
Code §415.021(c) and (c-2) and subsection (e) of this section.
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Source Note: The provisions of this §180.26 adopted to be effective January 9, 2011, 35 TexReg 11873; amended to be effective January 16, 2019, 44 TexReg 264; amended to be effective January 12, 2020, 45 TexReg 359 |