1 Tex. Admin. Code § 371.1669 - Self-Dealing
A person is subject to administrative actions or sanctions if the person:
(1) rebates or
accepts a fee or a part of a fee or charge for a Medicaid or other HHS program
patient referral;
(2) solicits
recipients or causes recipients to be solicited, through offers of
transportation or otherwise, for the purpose of claiming payment related to
those recipients;
(3) knowingly
offers to pay or agrees to accept, directly or indirectly, overtly or covertly,
any remuneration in cash or in kind to or from another for securing or
soliciting a patient or patronage for or from a person licensed, certified, or
registered by a state health care regulatory agency or HHS agency;
(4) knowingly offers to pay or agrees to
accept, directly or indirectly, overtly or covertly, any remuneration in cash
or in kind to or from another for securing or soliciting a patient or patronage
for or from a person licensed, certified, or registered by a state health care
regulatory agency, subject to the exceptions enumerated in Chapter 102, Texas
Occupations Code;
(5) solicits or
receives, directly or indirectly, overtly or covertly, any remuneration,
including any kickback, bribe, or rebate, in cash or in kind for referring an
individual to a person for the furnishing of, or for arranging the furnishing
of, any item or service for which payment may be made, in whole or in part,
under the Medicaid or other HHS program, provided that this paragraph does not
prohibit the referral of a patient to another practitioner within a
multispecialty group or university medical services research and development
plan (practice plan) for medically necessary services;
(6) solicits or receives, directly or
indirectly, overtly or covertly, any remuneration, including any kickback,
bribe, or rebate, in cash or in kind for purchasing, leasing, or ordering, or
arranging for or recommending the purchasing, leasing, or ordering of, any
good, facility, service, or item for which payment may be made, in whole or in
part, under the Medicaid or other HHS program;
(7) offers or pays, directly or indirectly,
overtly or covertly, any remuneration, including any kickback, bribe, or
rebate, in cash or in kind to induce a person to refer an individual to another
person for the furnishing of, or for arranging the furnishing of, any item or
service for which payment may be made, in whole or in part, under the Medicaid
or other HHS program, provided that this paragraph does not prohibit the
referral of a patient to another practitioner within a multispecialty group or
university medical services research and development plan (practice plan) for
medically necessary services;
(8)
offers or pays, directly or indirectly, overtly or covertly, any remuneration,
including any kickback, bribe, or rebate, in cash or in kind to induce a person
to purchase, lease, or order, or arrange for or recommend the purchase, lease,
or order of, any good, facility, service, or item for which payment may be
made, in whole or in part, under the Medicaid or other HHS program;
(9) provides, offers, or receives an
inducement in a manner or for a purpose not otherwise prohibited by this
section or §
102.001, Texas
Occupations Code, to or from a person, including a recipient, provider,
employee or agent of a provider, third-party vendor, or public servant, for the
purpose of influencing or being influenced in a decision regarding:
(A) selection of a provider or receipt of a
good or service under the Medicaid or other HHS program;
(B) the use of goods or services provided
under the Medicaid or other HHS program; or
(C) the inclusion or exclusion of goods or
services available under the Medicaid program;
(10) is a physician and refers a Medicaid or
other HHS program recipient to an entity with which the physician has a
financial relationship for the furnishing of designated health services,
payment for which would be denied under Title XVIII (Medicare) pursuant to
42 U.S.C. §
1395nn, §
1396b(s) (Stark
I, II, and III), the federal Anti-Kickback Statute, the Affordable Care Act, or
other state or federal law prohibiting self-dealing or self-referral;
(11) engages in marketing services in
violation of Texas Government Code §
545.0202, program
rules, or contract and has not received prior authorization from the program
for the marketing campaign; or
(12)
fails to disclose documentation of financial relationships necessary to
establish compliance with §1877 and §1903(s) of the Social Security
Act or 42 C.F.R.
§§
411.350 - .389 (Stark I, II, and
III), the federal Anti-Kickback Statute, the Affordable Care Act, or other
state or federal law prohibiting self-dealing or self-referral.
Notes
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