Common use of Provider Fraud Clause in Contracts

Provider Fraud. Billing for services not rendered, billing separately for services in lieu of an available combination code; misrepresentation of the service/supplies rendered (billing brand named for generic drugs; upcoding to more expensive service than was rendered; billing for more time or units of service than provided); altering claims, submission of any false data on claims, such as date of service, provider or prescriber of service, duplicate billing for the same service; billing for services provided by unlicensed or unqualified persons; billing for used items as new. Notwithstanding this requirement, the PH-MCO is not required to re-print handbooks for the sole purpose of revising them to include MA Provider Compliance Hotline information. The PH-MCO must, however, include such information in any new version of these documents to be distributed to Members and Providers.