Tex. Labor Code Section 413.016
Payments in Violation of Medical Policies and Fee Guidelines

(a)

The division shall order a refund of charges paid to a health care provider in excess of those allowed by the medical policies or fee guidelines. The division shall also refer the health care provider alleged to have violated this subtitle to the division of compliance and practices.

(b)

If the division determines that an insurance carrier has paid medical charges that are inconsistent with the medical policies or fee guidelines adopted by the commissioner, the division shall investigate the potential violation. If the insurance carrier reduced a charge of a health care provider that was within the guidelines, the insurance carrier shall be directed to submit the difference to the provider unless the reduction is in accordance with an agreement between the health care provider and the insurance carrier.
Acts 1993, 73rd Leg., ch. 269, Sec. 1, eff. Sept. 1, 1993.
Amended by:
Acts 2005, 79th Leg., Ch. 265 (H.B. 7), Sec. 3.239, eff. September 1, 2005.

Source: Section 413.016 — Payments in Violation of Medical Policies and Fee Guidelines, https://statutes.­capitol.­texas.­gov/Docs/LA/htm/LA.­413.­htm#413.­016 (accessed Jun. 5, 2024).

413.002
Medical Review 413.003
Authority to Contract 413.004
Coordination with Providers 413.006
Advisory Committees 413.007
Information Maintained by Division 413.008
Information from Insurance Carriers 413.011
Reimbursement Policies and Guidelines 413.012
Medical Policy and Guideline Updates Required 413.013
Programs 413.014
Preauthorization Requirements 413.015
Payment by Insurance Carriers 413.016
Payments in Violation of Medical Policies and Fee Guidelines 413.017
Presumption of Reasonableness 413.018
Review of Medical Care if Guidelines Exceeded 413.019
Interest Earned for Delayed Payment, Refund, or Overpayment 413.020
Division Charges 413.021
Return-to-work Coordination Services 413.022
Return-to-work Reimbursement Program for Employers 413.023
Information to Employers 413.024
Information to Employees 413.025
Return-to-work Goals and Assistance 413.031
Medical Dispute Resolution 413.032
Independent Review Organization Decision 413.041
Disclosure 413.042
Private Claims 413.043
Overcharging Prohibited 413.044
Sanctions on Designated Doctor 413.051
Contracts with Review Organizations and Health Care Providers 413.052
Production of Documents 413.053
Standards of Reporting and Billing 413.054
Immunity from Liability 413.055
Interlocutory Orders 413.0111
Processing Agents 413.0112
Reimbursement of Federal Military Treatment Facility 413.0115
Requirements for Certain Voluntary or Informal Networks 413.0141
Initial Pharmaceutical Coverage 413.0311
Review of Medical Necessity Disputes 413.0312
Review of Medical Fee Disputes 413.0511
Medical Advisor 413.0512
Medical Quality Review Panel 413.0513
Confidentiality Requirements 413.0514
Information Sharing with Occupational Licensing Boards 413.0515
Reports of Chiropractor Violations 413.05115
Medical Quality Review Process 413.05121
Quality Assurance Panel 413.05122
Medical Quality Review Panel: Rules
Green check means up to date. Up to date

Accessed:
Jun. 5, 2024

§ 413.016’s source at texas​.gov