Chapter 35A is the Texas health care fraud chapter. Section 35A.01 is its definitions provision — and in a prosecution under this chapter, the definitions frequently matter more than anything else.
What Section 35A.01 Does
It defines the terms used throughout the chapter, including health care benefit, health care provider, and the claims and programs the chapter reaches. Those definitions set the boundaries of the offense created by Section 35A.02, which makes it an offense to knowingly make or cause to be made a false statement or misrepresentation in connection with obtaining a health care benefit or payment.
Why the Definitions Decide Cases
Health care billing is extraordinarily complex, and the line between a billing dispute and a crime is drawn largely by these definitions and by the knowledge element in Section 35A.02.
Conduct that routinely gets investigated but often falls outside the offense:
- Coding errors and upcoding disputes where the provider's documentation supports a defensible interpretation
- Medical necessity disagreements — a payer's retrospective view that a service was not necessary is a coverage dispute, not proof of a knowing false statement
- Billing company and clearinghouse errors made without the provider's knowledge
- Documentation deficiencies — inadequate charting is a compliance problem, and the State must still prove a knowing misrepresentation
- Credentialing and supervision questions in group practices
Grading
Health care fraud under Section 35A.02 is graded by the value of the benefit obtained or attempted, following the theft value ladder — from misdemeanor levels at the lowest amounts to a first-degree felony at the highest. Because claims are aggregated across time, the value calculation is usually the most consequential contested issue, and extrapolation from a sample audit to a total "loss" figure is a standard and highly attackable government technique.
Who Prosecutes
Three possibilities, often simultaneously:
- The local district attorney;
- The Attorney General's Medicaid Fraud Control Unit, which has concurrent jurisdiction with the consent of the local prosecutor under Section 1.09; and
- Federal prosecutors, under the federal health care fraud and Anti-Kickback statutes.
The Parallel Proceedings Problem
A provider under investigation typically faces some combination of a civil recovery action, a False Claims Act qui tam suit, payment suspension, licensing board proceedings, and exclusion from Medicare and Medicaid. Statements made in any of those forums are available in the criminal case. They must be coordinated by counsel from the beginning — an explanation offered to an auditor becomes the government's exhibit.
If You Have Received a Records Request
These investigations begin quietly: a records demand, a payment suspension, an audit letter, or an interview request to a staff member. That is the moment to involve counsel — before documents are produced and before anyone gives an explanation.
Related
- Concurrent jurisdiction (1.09)
- Houston federal criminal defense · Professional licensure consequences
- Houston theft attorney
Charged in Harris County?
Brian Foley is Board Certified in Criminal Law by the Texas Board of Legal Specialization and a former Harris County Felony Chief Prosecutor; Luis Baez is a former Trial Bureau Chief. Call or text (713) 703-1718 for a free, confidential consultation.