Fraud and Abuse Unit Clause Samples
The Fraud and Abuse Unit clause establishes a dedicated team or department within an organization responsible for investigating, detecting, and preventing fraudulent or abusive activities. This unit typically monitors transactions, reviews internal processes, and conducts inquiries when suspicious behavior is reported or identified. By centralizing oversight and response to potential fraud or abuse, the clause helps protect the organization from financial losses, reputational harm, and legal liabilities.
Fraud and Abuse Unit. The PH-MCO must establish a Fraud and Abuse unit within the organization comprised of experienced Fraud and Abuse reviewers. This unit shall have the primary purpose of preventing, detecting, investigating, and reporting suspected Fraud and Abuse that may be committed by Network Providers, Members, employees, or other third parties with whom the PH-MCO contracts. If the PH-MCO has multiple lines of business, the Fraud and Abuse Unit shall devote sufficient time and resources to Pennsylvania HealthChoices Program Fraud and Abuse activities. The Department has the right to make the final determination regarding whether or not the Contractor is in compliance with this requirement.
Fraud and Abuse Unit. The PCO must maintain a Fraud and Abuse unit within the organization comprised of experienced Fraud and Abuse reviewers. This unit shall have the primary purpose of preventing, detecting, investigating, and reporting suspected Fraud and Abuse that may be committed by Network Providers, Members, employees, or other third parties with whom the PCO contracts.