Common use of Fraud and Abuse Unit Clause in Contracts

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.