Common use of Fraud, Waste and Abuse Unit Clause in Contracts

Fraud, Waste and Abuse Unit. The PH-MCO must establish a Fraud, Xxxxx and Abuse Unit comprised of experienced Fraud, Waste and Abuse reviewers as required in 42 C.F.R. §438.608(a)(1)(vii). This Unit must have the primary purpose of preventing, detecting, reducing, investigating, referring, and reporting suspected Fraud, Xxxxx and Abuse that may be committed by Network Providers, Members, Caregivers, Employees, or other third parties with whom the PH-MCO contracts. If the PH-MCO has multiple lines of business, the Fraud, Waste and Abuse Unit is required to have a dedicated full time HC MA investigator to Member ratio of at least one investigator per 60,000 members devoted to the HealthChoices Program’s Fraud, Waste and Abuse activities. The Department will make the final determination regarding whether or not the PH-MCO is in compliance with these requirements in accordance with 42 C.F.R. § 438.608(a)(7)).