Tex. Hum. Res. Code Chapter 36 in overview
The Texas Medicaid Fraud Prevention Act is codified at Texas Human Resources Code Chapter 36. The framework operates through multiple interconnected provisions organized into subchapters:
- Subchapter A — General Provisions. Definitions, scope, and the substantive unlawful acts under § 36.002. The substantive prohibitions parallel the federal FCA § 3729 framework while being calibrated to Texas Medicaid program specifics.
- Subchapter B — Civil Remedies. The damages framework under § 36.052 (and related sections) providing for recovery of unlawful payments, double damages, civil penalties, interest, and attorney’s fees.
- Subchapter C — Investigation and Enforcement. The Texas Attorney General’s investigation authority, civil investigative demand procedures, and coordination with the Medicaid Fraud Control Unit.
- Subchapter D — Civil Action by Private Person. The qui tam framework under § 36.101 et seq., including filing under seal, the State’s intervention decision, the relator share under § 36.110, and the procedural framework for private MFPA litigation.
- Subchapter E — Miscellaneous Provisions. Including § 36.115 — the anti-retaliation provision protecting workers who report Texas Medicaid fraud or participate in MFPA proceedings.
The MFPA’s structural relationship to federal Medicaid law
The Texas MFPA exists within a specific federal-state Medicaid law structure that affects how the framework operates:
Texas Medicaid is jointly funded. Under Title XIX of the Social Security Act (42 U.S.C. §§ 1396 et seq.), Medicaid is administered by states with federal matching funds. The Federal Medical Assistance Percentage (FMAP) for Texas is typically around 60%, with Texas state funds providing the balance. Fraud against Texas Medicaid implicates both federal funds (reachable under federal FCA) and state funds (reachable under Texas MFPA).
The MFCU framework is federally required. Under 42 U.S.C. § 1396b(q), states must maintain Medicaid Fraud Control Units as a condition of receiving federal Medicaid matching funds. The Texas MFCU operates within the Texas Attorney General’s office and has authority over Texas Medicaid fraud investigations. The federal HHS-OIG coordinates with state MFCUs nationwide.
The Texas Health and Human Services Commission Office of Inspector General (HHSC-OIG) has authority over Texas Medicaid administrative integrity matters and may conduct its own investigations parallel to MFCU criminal and civil investigations. The OIG framework operates under Tex. Gov’t Code Ch. 531 and related Texas administrative law.
Texas managed care has restructured fraud patterns. Most Texas Medicaid is administered through managed care organizations (MCOs) under contracts with HHSC. The MCO structure has shifted fraud patterns from direct provider-to-Medicaid claims to claims submitted to MCOs that are then encountered to Medicaid through capitation rate adjustments. The MFPA reaches both direct fraud against Medicaid and fraud committed against MCOs that affects Medicaid funding.
§ 36.002 — What constitutes a violation
Section 36.002 of the Texas Human Resources Code defines the unlawful acts that constitute MFPA violations. The framework parallels the federal FCA § 3729 structure while incorporating Texas Medicaid program specifics.
A person commits an unlawful act if the person: knowingly makes or causes to be made a false statement or misrepresentation of a material fact to permit a person to receive a benefit or payment under the Medicaid program that is not authorized or that is greater than the benefit or payment that is authorized; knowingly conceals or fails to disclose information that permits a person to receive a benefit or payment that is not authorized; knowingly applies for or receives a benefit or payment for medical services that the person was not entitled to receive; knowingly makes, causes to be made, induces, or seeks to induce the making of a false statement or misrepresentation of material fact concerning the conditions or operation of a facility in order that the facility may qualify for certification or recertification or that is required to be made or provided; and other categories of conduct enumerated in § 36.002.
The scienter requirement
The “knowingly” element under MFPA is defined in § 36.001 to include actual knowledge, deliberate ignorance, and reckless disregard — paralleling the federal FCA “knowingly” standard. The Texas framework reaches the same scienter range as the federal FCA, allowing relators to pursue MFPA claims under the same factual record that supports federal FCA standing.
Categories of MFPA violations
The § 36.002 framework reaches a broad range of conduct:
- False statements or misrepresentations to obtain Medicaid benefits or payments. The core substantive prohibition — including upcoding, unbundling, services billed but not rendered, and similar conduct.
- Concealment or failure to disclose information. Including overpayment retention (reverse false claims), failure to disclose ownership relationships, failure to disclose adverse credentialing actions, and similar concealment conduct.
- Application for or receipt of benefits not authorized. Including improper enrollment of patients, improper certification of medical necessity, and improper claims for services beyond authorized coverage.
- False statements regarding facility conditions or operation. Particularly relevant in LTC certification, ICF/IID certification, and waiver program certification contexts.
- Kickback-related conduct. The MFPA reaches kickback arrangements analogous to federal Anti-Kickback Statute violations, with kickback claims supporting MFPA liability.
- Conspiracy. The MFPA reaches conspiracy to commit any of the substantive violations.
- Other categories enumerated in § 36.002. The framework reaches a broader range of specific conduct categories than this overview can fully describe.
§ 36.101 et seq. — Private relator standing
Subchapter D of Chapter 36 establishes the qui tam framework allowing private relators to bring civil actions on behalf of the State of Texas. The framework parallels the federal FCA qui tam structure substantially but operates in Texas state court rather than federal court.
A private person may bring a civil action under the Texas Medicaid Fraud Prevention Act on behalf of the State of Texas to recover damages and penalties for violations of § 36.002. The action is brought in the name of the State. The complaint is filed under seal, served on the State of Texas, and remains under seal during the State’s investigation period. The State may intervene and pursue the action, or decline to intervene and allow the relator to proceed.
How MFPA qui tam actions proceed
The MFPA qui tam procedural framework operates through specific steps:
- The relator files the complaint under seal in Texas state district court. The relator files a sealed complaint along with a written disclosure of the material evidence and information. The complaint and disclosure go to the Texas Attorney General’s office.
- The complaint remains sealed during State investigation. The seal period and extension procedures are established by Chapter 36. The seal may be extended for substantial periods while the Texas Attorney General investigates.
- The Texas Attorney General investigates through the Medicaid Fraud Control Unit. The MFCU coordinates with the federal Department of Justice in jointly-funded Medicaid cases, with HHSC-OIG, and with federal HHS-OIG. The investigation may include witness interviews, civil investigative demands, document subpoenas, and parallel administrative review.
- The State decides whether to intervene. Like the federal FCA, the MFPA intervention decision is consequential — intervened cases proceed with the State as primary party, non-intervened cases proceed with the relator alone.
- The case proceeds to disposition. Settlement is the typical resolution in major Medicaid fraud cases. Where the case proceeds to judgment, Texas state court procedural rules govern.
- The relator share is calculated under § 36.110. The relator share calculation parallels the federal FCA framework, with the within-range share determined by the relator’s contribution and the public disclosure analysis.
The relator share under § 36.110
The Texas MFPA relator share framework parallels the federal FCA structure:
- Intervened cases. When the State intervenes and pursues the action, the relator typically receives a percentage of the State’s recovery — calibrated to provide adequate whistleblower incentive while ensuring the State retains the substantial majority of the recovery.
- Non-intervened cases. When the State declines to intervene and the relator proceeds alone, the relator share is higher to reflect the increased risk and resource commitment.
- Public disclosure adjustments. Where the action is based primarily on disclosures of information from public sources, the relator share may be reduced.
- Culpable relator limitations. Where the relator planned and initiated the fraud or was convicted of related criminal conduct, the share may be reduced or eliminated.
The MFPA relator share applies on top of any reinstatement, back pay, and other relief under the § 36.115 anti-retaliation provision — the two recovery streams operate independently.
§ 36.115 — Texas state law anti-retaliation
Section 36.115 of the Texas Medicaid Fraud Prevention Act provides Texas state law anti-retaliation protection for workers who report Texas Medicaid fraud or participate in MFPA proceedings.
An employee, contractor, or agent is entitled to relief if the person is discharged, demoted, suspended, threatened, harassed, or in any other manner discriminated against in the terms and conditions of employment because of lawful acts done by the employee, contractor, or agent or associated others in furtherance of an action under this chapter or other efforts to stop one or more violations of this chapter. Relief includes reinstatement, back pay, interest, compensation for special damages, and reasonable attorney’s fees and costs.
The two-pronged protected activity framework
Section § 36.115 reaches two categories of protected activity, paralleling federal § 3730(h):
Lawful acts in furtherance of an MFPA action. Filing an MFPA qui tam complaint, investigating fraud in preparation for filing, providing evidence to the Texas Attorney General, testifying in MFPA proceedings, and assisting in the prosecution of MFPA matters. The framework reaches both formal qui tam relators and pre-filing investigative conduct.
Other efforts to stop MFPA violations. The “other efforts” category reaches workers who report Medicaid fraud internally (to compliance officers, supervisors, hotlines), refuse to participate in fraudulent billing, raise concerns about billing practices, or otherwise oppose conduct they reasonably believe violates the MFPA. The protection does not require the worker to have filed or intended to file an MFPA qui tam action.
Damages under § 36.115
The § 36.115 damages framework includes:
- Reinstatement with seniority that the worker would have had absent retaliation
- Back pay with applicable interest and any statutory multiplier
- Compensation for special damages including mental anguish, professional reputation harm, and consequential damages
- Reasonable attorney’s fees and costs
The framework parallels federal § 3730(h) and operates concurrently with it in most cases. Where the MFPA retaliation case stacks with federal § 3730(h), the worker may recover under whichever framework provides broader relief on each component of damages.
The Texas Attorney General’s Medicaid Fraud Control Unit
The Texas Attorney General’s Medicaid Fraud Control Unit is the state agency responsible for Texas Medicaid fraud investigation and enforcement. The MFCU operates under federal authority (42 U.S.C. § 1396b(q) requires states to maintain MFCUs as a condition of federal Medicaid matching funds) and under Texas state law within the Texas Attorney General’s office.
MFCU jurisdiction and authority
The MFCU has authority over:
- Criminal investigation and prosecution of Texas Medicaid fraud. The MFCU includes prosecutors authorized to pursue criminal charges under Texas Penal Code provisions and federal criminal statutes.
- Civil MFPA enforcement. The MFCU pursues civil recoveries under Chapter 36 against providers, MCOs, and others who have committed Texas Medicaid fraud.
- Patient abuse and neglect investigation in Medicaid-funded facilities. The MFCU has authority to investigate abuse and neglect of patients at facilities receiving Medicaid funding — including nursing homes, ICF/IIDs, behavioral health facilities, and other Medicaid-funded facilities.
- Misappropriation of patient funds. The MFCU investigates theft of patient personal funds at Medicaid-funded facilities.
- Coordination with federal partners. The MFCU coordinates with the federal Department of Justice, HHS-OIG, FBI, and other federal investigators in matters involving both federal and state Medicaid funds.
MFCU investigation in qui tam matters
When an MFPA qui tam complaint is filed under seal, the Texas Attorney General — through the MFCU — typically conducts the investigation during the seal period. The investigation may include:
- Witness interviews coordinated with the relator’s counsel
- Document subpoenas and civil investigative demands under Chapter 36
- Coordination with HHSC-OIG for administrative records and audit findings
- Coordination with federal DOJ and HHS-OIG in jointly-funded cases
- Parallel criminal investigation in matters with criminal exposure
- Settlement negotiation with defense counsel where appropriate
The State’s intervention decision
Before the seal is lifted, the State of Texas must decide whether to intervene under the procedures established in Chapter 36. The intervention decision shapes the case trajectory:
- State intervention. The State takes the lead. The MFCU drives litigation and settlement strategy. The relator’s role becomes supportive. The relator share is typically calculated within the lower percentage band.
- State declination. The State declines to intervene. The relator may proceed alone with private counsel. The relator share is typically calculated within the higher percentage band to reflect the increased risk and resource commitment.
The Texas-specific Medicaid program landscape
Texas Medicaid is administered through a complex set of programs and managed care arrangements. Each program has its own fraud risk profile, and the MFPA framework reaches fraud across the entire Texas Medicaid landscape.
Texas Medicaid managed care for most low-income families, pregnant women, and children. Administered through contracted MCOs. Fraud patterns include encounter data manipulation, denial of medically necessary services, network adequacy fraud, and capitation rate manipulation.
MFPA · Federal FCA · MCO complianceTexas Medicaid managed care for elderly and disabled adults. Integrates long-term services and supports with acute care. Fraud patterns include LTSS hours manipulation, MCO denial of community-based services, nursing facility billing fraud, and attendant care fraud.
MFPA · §260A.014 · §161.134Texas Medicaid managed care for children with disabilities. Includes specialty pediatric services, durable medical equipment, behavioral health, and waiver services. Fraud patterns include therapy services billing fraud, DME fraud, and waiver service hours manipulation.
MFPA · §261.110 · Federal FCATexas Medicaid managed care for children in DFPS conservatorship. Specialized program addressing the complex needs of foster children. Fraud patterns include psychotropic medication fraud, behavioral health overbilling, and inadequate medical care concealed through documentation fraud.
MFPA · §261.110 · §161.134Texas Medicaid waiver providing community-based services for individuals with intellectual and developmental disabilities. Fraud patterns include attendant care services billed but not rendered, day habilitation fraud, residential services fraud, and ICF/IID-to-HCS transition fraud.
MFPA · §260A.014 · Federal FCATexas Medicaid waiver providing limited home-based services for individuals with IDD who do not require HCS-level services. Fraud patterns include service hours manipulation, billing for services not provided, and improper waiver eligibility certification.
MFPA · Federal FCACommunity Living Assistance and Support Services waiver providing community-based services for individuals with related conditions. Fraud patterns parallel HCS and TxHmL — attendant care fraud, day habilitation fraud, residential fraud, eligibility certification fraud.
MFPA · Federal FCATexas Medicaid waiver providing community-based services for children with complex medical needs. Includes Prescribed Pediatric Extended Care Centers (PPECCs) as a covered service. Fraud patterns include PPECC billing fraud, in-home nursing service fraud, and medical necessity documentation fraud.
MFPA · §260A.014 · §261.110Texas Medicaid non-emergency medical transportation program. Historically subject to substantial fraud — transportation services billed but not rendered, ghost passenger fraud, kickback arrangements between MTP providers and medical providers.
MFPA · Federal FCATexas Medicaid dental services for children under EPSDT and limited adult coverage. Historically one of the largest Texas Medicaid fraud areas, particularly orthodontia. Fraud patterns include medically unnecessary orthodontia, upcoded dental procedures, services not rendered, and documentation fraud.
MFPA · Federal FCATexas Medicaid pharmacy benefits administered through the Texas Vendor Drug Program and Medicaid MCO pharmacy networks. Fraud patterns include 340B drug diversion affecting Texas Medicaid, double-dipping between Medicaid and 340B, drug substitution fraud, and pharmacy billing fraud. See the firm’s pharmacy staff page.
MFPA · Federal FCA · 340BTexas Medicaid nursing facility coverage, ICF/IID coverage, and community-based LTSS. Fraud patterns include PDPM-related billing manipulation, ICF/IID level-of-care fraud, unnecessary therapy services, and facility cost report fraud.
MFPA · §260A.014 · Federal FCAThe settings list is illustrative. The MFPA reaches Texas Medicaid fraud across every program and every provider type — direct providers, MCOs, sub-contractors, billing agents, durable medical equipment suppliers, transportation providers, and any other entity participating in the Texas Medicaid funding stream.
The Texas managed care organization landscape
Texas administers most of its Medicaid program through managed care organizations contracted with the Texas Health and Human Services Commission. The MCO structure means most Texas Medicaid fraud passes through an MCO — either as direct fraud against the MCO that affects Medicaid funding, or as MCO-level fraud in claims to HHSC.
MCO-level fraud patterns
MFPA matters involving MCOs typically address fraud at the MCO level rather than (or in addition to) fraud by individual providers:
- Encounter data manipulation. MCOs are paid through capitation rates calibrated based on encounter data reflecting services provided to enrolled members. Manipulation of encounter data — either understating services to reduce future capitation adjustments or overstating services to increase risk-adjusted payments — affects Medicaid funding.
- Risk adjustment manipulation. MCOs receive higher capitation for members with documented chronic conditions. Improper diagnosis coding to increase risk scores affects Medicaid funding.
- Denial of medically necessary services. Where MCOs deny services that meet medical necessity criteria, the practice may constitute MFPA violations by reducing the value provided in exchange for capitation payments — a “worthless services” theory adapted to managed care.
- Network adequacy fraud. Where MCO networks do not provide adequate access to contracted services, the practice may constitute fraud against HHSC and Medicaid funding.
- Provider directory fraud. Inaccurate provider directories misrepresenting network composition.
- Sub-capitation arrangements. Where MCOs sub-capitate to provider groups in arrangements that incentivize service denial or fraud, the resulting conduct affects Medicaid funding.
Texas-specific Medicaid fraud patterns
The Texas Medicaid program has distinctive fraud patterns reflecting Texas-specific program structures, provider markets, and regulatory environments.
Texas Medicaid orthodontia was historically subject to extensive fraud. Texas Medicaid covers orthodontia for children with documented severe malocclusion meeting specific HHSC criteria. Multiple dental practices and orthodontic chains were found to have systematically billed for orthodontia not meeting the medical necessity criteria, with documentation fraud supporting medically unnecessary treatment. Major Texas Medicaid orthodontia settlements in the early 2010s produced substantial recoveries. The orthodontia framework has been substantially restructured since, but Texas Medicaid dental claims continue to face scrutiny.
Texas Medicaid waiver programs (HCS, TxHmL, CLASS, MDCP) include attendant care services as a major covered service. Common fraud patterns include attendant hours billed but not provided, ghost attendant fraud (billing for attendant time that did not occur), attendant qualification fraud (billing services as performed by qualified personnel when actually performed by unqualified personnel), and family member attendant fraud where the attendant relationship does not meet program requirements. Waiver attendant care fraud is particularly difficult to detect because the services are provided in private homes with limited direct oversight.
The Texas Medicaid Medical Transportation Program provides non-emergency medical transportation for Medicaid recipients. Common fraud patterns include trips billed but not provided (ghost trips), trips billed in vehicles that were not actually used, kickback arrangements between MTP providers and medical providers (paying for referrals), and trips provided in vehicles that did not meet MTP equipment or accessibility requirements.
Prescribed Pediatric Extended Care Centers serve children with medical complexity in Texas. PPECCs operate under HHSC licensure and receive Texas Medicaid payments for nursing services. Common fraud patterns include nursing hours billed but not provided, services billed for ineligible patients, documentation fraud supporting medical necessity determinations, and improper certification of nursing intensity levels.
Texas Medicaid skilled nursing facility coverage and ICF/IID coverage depend on level-of-care determinations. Common fraud patterns include LOC determinations supporting reimbursement levels not justified by patient acuity, MDS (Minimum Data Set) manipulation for SNF reimbursement, ICAP score manipulation for ICF/IID reimbursement, and therapy services billed at higher levels than provided.
Federal IMD exclusion limits Medicaid coverage for behavioral health services in Institutions for Mental Diseases. Texas behavioral health operators have used various structures to obtain Medicaid coverage notwithstanding the IMD exclusion — including operating multiple smaller facilities (under 16 beds) to avoid IMD designation, manipulating discharge timing, and structuring services to avoid IMD classification. The MFPA reaches IMD exclusion violations affecting Texas Medicaid funding. See the firm’s behavioral health page.
As Texas Medicaid has shifted to MCO administration, fraud patterns have followed. MCO encounter data fraud affects capitation rate adjustments and risk scoring. The pattern is structurally different from direct provider fraud — the MCO submits encounter data to HHSC, and manipulation at the MCO level affects Medicaid funding even if individual provider claims to the MCO were technically accurate.
Texas Medicaid pharmacy intersects with the federal 340B Drug Pricing Program in complex ways. Common fraud patterns include 340B drug diversion to Texas Medicaid patients combined with billing Medicaid at non-340B prices (double-dipping), 340B prescription routing to Medicaid managed care for additional rebates, and 340B-eligible patient identification fraud. See the firm’s pharmacy staff page and the firm’s federal FCA page.
Texas STAR Health (the Medicaid managed care program for foster children) has historically faced concerns about psychotropic medication overprescribing. Common fraud patterns include psychotropic medications prescribed without proper assessment, off-label prescribing without medical necessity, polypharmacy without coordination, and documentation fraud supporting prescribing patterns.
Texas Medicaid home health services and personal assistance services have specific eligibility, documentation, and service delivery requirements. Common fraud patterns include services billed but not provided, services provided by unqualified personnel billed as if provided by qualified personnel, plan of care fraud, and physician certification fraud.
How MFPA stacks with the federal False Claims Act
In Texas Medicaid fraud cases, the MFPA and the federal FCA almost always operate concurrently. The stacking dynamic is the central feature of Texas Medicaid qui tam practice.
The federal-state Medicaid funding split
Texas Medicaid is funded approximately 60% by federal Medicaid matching funds and 40% by Texas state funds. Fraud against Texas Medicaid therefore affects both federal and state funding streams in roughly that proportion. The federal share is reached by the federal FCA; the state share is reached by the Texas MFPA. Most healthcare fraud relators file parallel actions:
- Federal FCA qui tam complaint filed under seal in federal district court
- Texas MFPA qui tam complaint filed under seal in Texas state district court
The two complaints address the same underlying fraud but reach different funding streams. The DOJ and Texas MFCU typically coordinate investigation. Settlement negotiations typically address both federal and state recoveries simultaneously, with the relator share calculated on each component.
Procedural coordination
Parallel federal-state qui tam practice requires substantial procedural coordination:
- Filing strategy. Parallel complaints typically filed contemporaneously, with the relator and the relator’s counsel coordinating across federal and state forums.
- Seal coordination. Both seals operate concurrently. Disclosure restrictions during seal periods apply across both forums.
- Investigation coordination. DOJ and Texas MFCU typically conduct joint investigation or closely coordinate parallel investigations. Witness interviews, document subpoenas, and other investigation work may serve both forums.
- Intervention coordination. The federal intervention decision and the Texas State intervention decision are made independently but with awareness of each other. It is common for both to intervene, both to decline, or for one to intervene while the other declines.
- Settlement coordination. Settlement of jointly-funded fraud cases typically resolves both federal and state components simultaneously with proportional recovery allocation.
- Trial coordination. If the case proceeds to trial, careful coordination is required to manage parallel federal and state proceedings, with potential issues around inconsistent rulings, witness availability, and forum-specific evidentiary rules.
How MFPA stacks with Texas retaliation statutes
The MFPA framework operates concurrently with Texas setting-based retaliation statutes in most healthcare contexts. The combination produces overlapping protections and damages frameworks.
The federal FCA is the MFPA’s primary federal counterpart, reaching the federal share of Texas Medicaid funding. Both frameworks have substantive liability provisions, qui tam standing, relator share frameworks, and anti-retaliation provisions. The federal § 3730(h) anti-retaliation framework has a three-year statute of limitations more generous than typical Texas state retaliation windows. See the firm’s federal FCA page for full treatment.
For hospital workers and treatment facility workers reporting Texas Medicaid fraud, §161.134 operates alongside § 36.115. The 60-day rebuttable presumption under §161.134(f) and the 179-day actionable window apply. The firm’s published Texas appellate authority in SJ Medical Center, LLC v. Anozie is the controlling §161.134 / EFAA decision in Texas. See the firm’s §161.134 statutory page.
For workers at SNFs, ALFs, ICF/IIDs, and PPECCs reporting Medicaid fraud, §260A.014 operates alongside § 36.115. The §260A.014(a) broad employee definition reaches contract workers. Damages include a $1,000 statutory floor and the §260A.014(h) two-year backstop. See the firm’s §260A.014 statutory page.
For nurses reporting Texas Medicaid fraud, the Nursing Practice Act anti-retaliation provision operates alongside § 36.115. The §301.413 “a person” framing also reaches anyone who advises a nurse of reporting rights. See the firm’s §301 NPA statutory page.
For Texas social workers (LCSWs, LMSWs) at healthcare operators, the social work-specific anti-retaliation framework operates alongside § 36.115. The framework reaches behavioral health social workers, case managers, hospital social workers, and child welfare social workers at Medicaid-funded operations.
For workers at publicly-traded Texas Medicaid operators or publicly-traded operators of MCOs administering Texas Medicaid, SOX §806 operates alongside § 36.115 and federal § 3730(h). Texas MCO parent operators that are publicly-traded include Anthem (Amerigroup parent), Centene (Superior parent), Molina, UnitedHealth, CVS Health (Aetna parent), and Cigna.
Where the MFPA retaliation involves refusal to perform an illegal act carrying criminal penalties (Texas Penal Code provisions on Medicaid fraud, theft, securing execution of document by deception, and similar offenses), Sabine Pilot common law provides a parallel cause of action.
The structural significance of the MFPA framework
The Texas MFPA is not simply a state-level copy of the federal FCA. The framework has distinctive features that affect how Texas Medicaid fraud practice operates.
Parallel federal-state filings are the rule, not the exception. Because Texas Medicaid is jointly federal-state funded, Texas Medicaid fraud almost always implicates both funding streams. Sophisticated qui tam practice requires parallel federal FCA and Texas MFPA filings to reach both components. Relators who file only federal FCA actions may forfeit relator share on the substantial Texas state recovery.
Texas-specific Medicaid programs create distinctive fraud patterns. The Texas Medicaid landscape — STAR managed care, multiple waiver programs (HCS, TxHmL, CLASS, MDCP), Medical Transportation Program, dental program, PPECCs — has fraud patterns that do not map onto general Medicare or federal Medicaid fraud frameworks. The MFPA reaches Texas-specific patterns that may be invisible to federal FCA practitioners without Texas-specific expertise.
The Texas MCO landscape concentrates fraud risk at the MCO level. Because most Texas Medicaid is administered through MCOs, fraud increasingly occurs at the MCO level rather than the individual provider level. Encounter data manipulation, risk adjustment fraud, denial of medically necessary services, and network adequacy fraud are MCO-level patterns that require Texas-specific framework expertise to identify and prosecute.
The Texas AG MFCU is a substantial enforcement partner. The Texas MFCU has built substantial expertise in Texas Medicaid fraud and pursues both criminal and civil enforcement. Relators with strong Texas MFPA matters typically benefit from substantial Texas state-side investigation support, particularly in cases involving Texas-specific fraud patterns.
The § 36.115 anti-retaliation framework operates concurrently with federal § 3730(h). Workers facing retaliation for reporting Texas Medicaid fraud have parallel state and federal causes of action. The cumulative damages framework, multiple presumptions, and parallel fee-shifting provisions across federal and state forums provide substantial leverage in retaliation litigation.
The cross-statute stacking is particularly powerful for Texas healthcare workers. A nurse reporting Texas Medicaid fraud at a hospital has claims under § 36.115 (MFPA), §161.134 (hospital), §301.413 (NPA), and federal § 3730(h). A behavioral health worker reporting Medicaid fraud at a residential facility has claims under § 36.115, §260A.014, §505.603, and federal § 3730(h). The cumulative framework substantially exceeds what any single statute would provide.
How the firm approaches Texas MFPA matters
Doyle Dennis Avery LLP represents both qui tam relators and § 36.115 retaliation plaintiffs in Texas Medicaid fraud matters. The firm’s MFPA practice operates in tandem with the firm’s federal FCA practice — in most Texas Medicaid fraud cases, parallel federal FCA and Texas MFPA filings are required to reach both federal and state funding components, and the firm handles both within a single integrated representation.
The firm’s MFPA practice covers the complete state-court qui tam representation: pre-filing investigation including substantive fraud analysis under § 36.002, qui tam standing analysis, and the parallel federal FCA standing analysis; preparation and filing of the sealed complaint under § 36.101 in Texas state district court; coordination with the Texas Attorney General’s Medicaid Fraud Control Unit and (in jointly-funded cases) with the federal Department of Justice through the investigation period and the State’s intervention decision; settlement negotiation including relator share advocacy across both federal and state recoveries; and litigation through trial in non-intervened or partially intervened cases. For § 36.115 anti-retaliation matters, the firm coordinates the multi-statute claim development across § 36.115, federal § 3730(h), and applicable Texas setting-based retaliation statutes.
Two of the firm’s named partners are board certified by the Texas Board of Legal Specialization. Jeffrey Avery is board certified in Labor and Employment Law. Michael Patrick Doyle is board certified in Personal Injury Trial Law. The firm’s published Texas appellate authority in Salas v. Fluor Daniel Services Corp., 616 S.W.3d 137, provides directly transferable authority for piercing “performance” and “reduction-in-force” pretexts that recur in MFPA retaliation cases. The firm’s published Texas appellate authority in SJ Medical Center, LLC v. Anozie is the controlling §161.134 / EFAA decision in Texas — directly applicable to MFPA retaliation matters where parallel §161.134 claims involve sexual misconduct dimensions.
The firm’s intake process for MFPA matters typically opens with a confidential initial consultation. For qui tam relator candidates, documentation review focuses on the substantive Texas Medicaid fraud evidence — Texas Medicaid claims data, MCO encounter data analysis, waiver program documentation, dental and orthodontia documentation, transportation program records, internal communications regarding billing practices to Texas Medicaid or to contracted MCOs, compliance audits and findings, AKS relationship analysis where applicable, and the federal-state allocation analysis identifying the proportional fraud against federal Medicaid matching funds versus Texas state funds. For § 36.115 retaliation matters, documentation review focuses on the protected-activity record across § 36.115 and federal § 3730(h), the adverse-action timeline, the worker’s professional history, employment paperwork including arbitration agreement analysis, and any parallel licensing board or regulatory matter. A written intake analysis identifies the operative statutes, the parallel federal FCA standing analysis, the cumulative presumption and damages framework, the qui tam standing analysis including public disclosure and first-to-file considerations, the limitations posture, and the procedural sequencing. Where the matter meets the firm’s criteria, representation proceeds on a contingency basis.
Workers’ compensation retaliation case where the trial court had granted summary judgment on the employer’s reduction-in-force defense. The Court of Appeals reversed and remanded. The published opinion is directly transferable to § 36.115 MFPA retaliation cases involving “performance,” “fit,” reduction-in-force, or contract non-renewal pretexts — the circumstantial-evidence framework applies the same way in Texas state court MFPA retaliation litigation.
Workers’ compensation retaliation matter. Verdict included $750,000 in exemplary damages on a gross negligence finding. The proof framework — circumstantial-evidence retaliation proof through documentary contradiction, witness inconsistency, and policy-based cross-examination — transfers directly to MFPA § 36.115 retaliation cases.
The firm represented the appellee in an interlocutory appeal from denial of motion to compel arbitration. The decision applies to MFPA retaliation matters with sexual misconduct dimensions, providing controlling Texas appellate authority for defeating compelled arbitration of § 36.115 retaliation claims that overlap with §161.134 claims.
§260A.014 long-term care retaliation matter on behalf of two co-claimants. The damages framework transfers to MFPA retaliation matters in LTC Medicaid contexts where § 36.115 and §260A.014 stack alongside federal § 3730(h).
Federal contractor whistleblower representation at a federally funded ORR Unaccompanied Children Program facility. The matter illustrates the federal healthcare framework directly applicable to MFPA practice where federally funded Texas healthcare operations also receive Texas Medicaid funding.
Whistleblower retaliation matter. A unanimous jury returned $1.1 million on a willful violation finding; final judgment, including prejudgment interest, costs, and statutory attorney’s fees, totaled approximately $1.97 million. The damages framework transfers to all whistleblower retaliation matters including MFPA § 36.115 cases.
Invited presentations by trial counsel addressing circumstantial-evidence retaliation proof transferable across statutory frameworks — including Texas state and federal Medicaid fraud whistleblower contexts.
What MFPA whistleblowers ask
What is the Texas Medicaid Fraud Prevention Act?
How does the Texas MFPA interact with the federal False Claims Act?
What does § 36.115 protect?
What is the Texas Attorney General’s Medicaid Fraud Control Unit?
What kinds of fraud does the Texas MFPA cover?
What share of recovery can an MFPA relator receive?
What damages does the Texas MFPA authorize?
What is the Texas MCO landscape?
How does Texas Medicaid dental fraud fit the framework?
What patterns of retaliation arise under § 36.115?
How long do I have to bring an MFPA qui tam or retaliation claim?
The Texas MFPA framework operates alongside the federal FCA. Most Texas Medicaid fraud cases require parallel filings in both forums.
If you have knowledge of fraud against the Texas Medicaid program — Texas MCO fraud, Texas Medicaid waiver attendant care fraud, dental orthodontia fraud, Medical Transportation Program fraud, 340B drug diversion affecting Texas Medicaid, behavioral health IMD fraud, LTC level-of-care fraud, or other conduct that may violate Tex. Hum. Res. Code § 36.002 — you may have standing to file qui tam actions under both Texas MFPA § 36.101 and federal FCA § 3730(b) with relator share recovery in both forums. Parallel federal-state filings are typical and the first-to-file rule applies in both forums. If you have already faced retaliation for reporting Texas Medicaid fraud, refusing to participate in fraud, or otherwise opposing MFPA violations, you have separate claims under § 36.115 and federal § 3730(h), along with parallel claims under applicable Texas setting-based statutes (§161.134, §260A.014, §301.413, §505.603) and federal frameworks (SOX §806 for publicly-traded MCO operators). Consultations are confidential and free. Early counsel involvement matters substantially — the parallel federal-state qui tam framework requires careful pre-filing analysis across both jurisdictions.
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