SECTION 187.88. Complaint Process and Resolution

(a) A complaint relating to a mediation may be filed by a mediator with the Board against a facility-based physician for bad faith mediation. Conduct constituting bad faith mediation includes:

(1) failing to participate in a mediation;

(2) failing to provide information the mediator believes is necessary to facilitate an agreement; or

(3) failing to designate a representative participating in the mediation with full authority to enter into any mediated agreement.

(b) If the enrollee is not satisfied with a mediated agreement, the enrollee may file a complaint with the Board against a facility-based physician for improper billing reached under Chapter 1467 of the Insurance Code.

(c) Investigations.

(1) All complaints shall be investigated pursuant to Chapter 179 of this title (relating to Investigations) and referred to an informal settlement conference if appropriate.

(2) In accordance with §311.0025 of the Health and Safety Code, the Board shall not open investigations relating to complaints of a single instance of improper billing, but shall open investigations on facility-based physicians who are alleged to have engaged in improper billing in multiple instances.

(d) Penalties.

(1) Bad Faith Mediation. Except for good cause shown, on a report of a mediator and appropriate proof of bad faith mediation, the Board shall impose an administrative penalty.

(2) Improper Billing. If the Board determines that a facility-based physician has engaged in improper billing practices, the Board shall impose sanctions consistent with §190.14 of this title (relating to Disciplinary Sanction Guidelines).

Source Note: The provisions of this §187.88 adopted to be effective May 2, 2010, 35 TexReg 3279; amended to be effective January 20, 2014, 39 TexReg 284; amended to be effective February 21, 2016, 41 TexReg 1119