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Physicians typically view billing and coding decisions as administrative. But claims based on inaccurate billing can create serious professional consequences. When the TMB believes a physician engaged in improper billing practices, that physician’s medical license may be in jeopardy.
Gardner Employment Law has considerable experience guiding physicians through discipline with the TMB. In this article, we recount a true case in which a physician’s inaccurate billing practices led to the revocation of the physician’s license.
What Happens When the TMB Discovers a Physician’s Inaccurate Billing Practices?
If the TMB (Texas Medical Board) concludes that a physician is indeed guilty of maintaining inaccurate billing practices, the TMB can impose penalties up to and including the revocation of a physician’s license. The TMB takes the topic of billing very seriously. Therefore, it almost goes without saying that physicians must assure that their billing records are accurate.
In this case, an actual case before the TMB, a physician came under scrutiny after a complaint was filed and a Board investigator started looking into the physician’s billing practices. The investigator saw that the physician had submitted claims that were not supported by proper documentation. Also, the TMB learned that the physician’s license had been revoked by another jurisdiction.
The TMB contacted the physician regarding her unreported license revocation in a letter that also requested information regarding her practice and the patients she was treating. However, the physician never responded. The physician committed a gross error by not responding quickly. As we explained in “How to Respond to a TMB Complaint,” a physician must file a timely response to an inquiry from the TMB.
Following multiple attempts to reach the physician, the Board opened a formal investigation into the physician’s practice. During the investigation, the Board found multiple instances of behavior that was likely to deceive or defraud the public.
Investigators determined that the physician had engaged in repeated inappropriate billing practices, including claims that overstated or misrepresented the services provided. These concerns were not isolated incidents. The TMB concluded that the billing conduct was serious enough to call the physician’s integrity and professional judgment into question.
While going through the physician’s billing records, the investigators could see that documentary support was inadequate and that many inconsistencies appeared in the files. They found a myriad of errors. Therefore, the TMB investigators determined that her conduct was misaligned with the professional standards. The TMB revoked the physician’s medical license.
This case demonstrates that billing conduct alone can create substantial disciplinary exposure.
Why Does the TMB Take Billing Violations So Seriously?
The TMB views and investigates inaccurate or misleading billing claims as evidence of broader concerns involving honesty, ethics, and patient trust. The Board regulates physicians’ billing practices the Texas Medical Practice Act.
Billing-related investigations may involve allegations such as:
- Upcoding or overbilling
- Billing for services not rendered
- Improper documentation supporting claims
- Misrepresenting the complexity of services provided
- Submitting duplicate or misleading claims
- Failure to maintain accurate patient records
The Board’s concern is not limited to whether the payor, usually an insurance carrier, lost money. Regulators also evaluate whether the physician’s conduct demonstrates dishonesty or an inability to comply with professional standards expected of licensed physicians.
Billing-related investigations may begin outside the TMB itself. Insurance carriers, government healthcare programs, auditors, former employees, or other providers may file complaints or reports. Once the issue reaches the Board, investigators may review:
| Stage | Details |
| Complaint Source | Insurance audits, government agencies, whistleblowers, former employees, or patient complaints |
| Investigation Trigger | Allegations of inaccurate claims, overbilling, or unsupported coding |
| Board Review Focus | Billing records, coding practices, supporting documentation, and professional conduct |
| Heightened Scrutiny | Repeated discrepancies, unsupported claims, or evidence suggesting intentional misconduct |
In cases involving repeated billing irregularities, the Board may determine that the conduct reflects a larger pattern of unprofessional behavior rather than a simple administrative mistake.
Physician-patient relationships are built on trust. Therefore, the TMB considers repeated billing inaccuracies as a betrayal of the trust relationship.
What Can Physicians Learn From Cases Like This?
This case highlights the importance of maintaining professional integrity when it comes to billing practices, as well as accurate billing documentation. The case also serves as a warning that even errors in performing administrative duties, such as properly documenting billing, can raise the TMB’s suspicion. The physician is responsible.
First, physicians should understand that billing compliance is not purely administrative. Coding and billing practices are a part of professional conduct and may directly affect licensure.
Second, documentation must support every claim submitted. Medical records should clearly establish:
- The services performed
- The medical necessity for treatment
- The complexity of the encounter
- The time and procedures billed
- Any supporting diagnostic or treatment decisions
Third, physicians should maintain strong oversight of billing staff, outside billing companies, and compliance systems. Delegating billing responsibilities does not eliminate professional responsibility.
Finally, physicians should take audits, payer inquiries, and billing complaints seriously from the start. Early compliance review may prevent an administrative issue from escalating into a formal Board investigation.
How Can You Protect Yourself?
Improper billing practices can lead to discipline by the TMB and may result in the loss of a physician’s license.
Understanding billing requirements, maintaining accurate documentation, and implementing effective compliance safeguards can help physicians reduce the risk of disciplinary action and protect both their licenses and professional reputations. If you have any concerns regarding the TMB or your practice’s billing procedures, we are here to help.