Section 180.26 - Criteria for Imposing, Recommending and Determining Sanctions; Other Remedies(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: (1) reduction of allowable reimbursement to a doctor (such as an automatic percentage reduction on all or some types of health care);(2) mandatory preauthorization or utilization review of all or certain health care treatments and services (such as mandatory treatment plans);(3) required supervision or peer review monitoring, reporting, and audit (by the insurance carrier, the division, or an independent auditor or reviewer);(4) deletion or suspension from the designated doctor list;(5) restrictions on appointments or reviews;(6) conditions or restrictions on an insurance carrier regarding actions by insurance carriers under the Act and rules, that are not inconsistent with a memorandum of understanding adopted between the commissioner and the commissioner of insurance regarding the regulation of insurance carriers and utilization review agents as necessary to ensure that appropriate health care decisions are reached under applicable regulations by the department and the division, the Act, and Chapter 4201, Insurance Code; and(7) mandatory participation in training classes or other courses as established or certified by the division.(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 Section 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.28 Tex. Admin. Code § 180.26
The provisions of this §180.26 adopted to be effective January 9, 2011, 35 TexReg 11873; Amended by Texas Register, Volume 44, Number 02, January 11, 2019, TexReg 268, eff. 1/16/2019; Amended by Texas Register, Volume 45, Number 02, January 10, 2020, TexReg 362, eff. 1/12/2020