2025 AHIP - Fraud, Waste, And Abuse Questions And Answers Latest Top Score

2025 AHIP - Fraud, Waste, And Abuse Questions And Answers Latest Top Score What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? - ANSWER -All of the above Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)? - ANSWER -Deportation You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? - ANSWER -Follow your pharmacy's procedures. A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160. You review the prescription and have concerns about possible forgery. What is your next step? - ANSWER -Call the prescriber to verify the quantity You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large patient group. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do? - ANSWER -Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which includes Medicare) constitute fraud by the person making as well as the person receiving them. - ANSWER -True Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the Anti-Kickback Statute, and the Criminal Health Care Fraud Statute. - ANSWER -True You can help prevent fraud, waste, and abuse (FWA) by doing all the following: Look for suspicious activity Conduct yourself in an ethical manner Ensure accurate and timely data and billing Ensure you coordinate with other payers Keep up to date with FWA policies and procedures, standards of conduct, laws, regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance Verify all information provided to you - ANSWER -True Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly or intentionally misrepresented facts to obtain payment. - ANSWER -True Waste includes any misuse of resources, such as the overuse of services or other practices that directly or indirectly result in unnecessary costs to the Medicare Program. - ANSWER -True Any person who knowingly submits false claims to the Government is liable for five times the Government's damages caused by the violator plus a penalty. - ANSWER -False These are examples of issues that should be reported to a Compliance Department: suspected fraud, waste, and abuse (FWA); potential health privacy violation, unethical behavior, and employee misconduct. - ANSWER -True Ways to report potential fraud, waste, and abuse (FWA) include: - ANSWER -All of the above Once a corrective action plan is started, the corrective action plan must be monitored annually to ensure they are effective. - ANSWER –False Which of the following requires intent to obtain payment and the knowledge the actions are wrong? - ANSWER -Fraud Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purpose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do? - ANSWER -Report the incident to the compliance department (via compliance hotline or other mechanism)