AHIP 2026 - MEDICARE FRAUD, WASTE, & ABUSE FINAL EXAM 2026 WITH
100% ACCURATE ANSWERS
SECTION 1: FUNDAMENTALS OF FRAUD, WASTE & ABUSE (Questions 1-35)
Q1. According to the healthcare fraud criminal statute, what penalties can be
imposed for defrauding a healthcare benefit program?
A) Only civil monetary penalties
B) Fines and up to 10 years in prison (or longer if death results)
C) Only exclusion from Medicare programs
D) Community service and probation only
Answer: B
Rationale: The criminal healthcare fraud statute (Section 1347 of Title 18) imposes
criminal penalties including fines and imprisonment of up to 10 years (or up to life
in prison if the violation resulted in a person's death).
,Q2. CMS defines "abuse" as:
A) Intentional deception to obtain something of value
B) Payment for items or services when there is no legal entitlement and the
provider has not knowingly misrepresented facts
C) Overutilization of services resulting in unnecessary costs to Medicare
D) Knowingly submitting false claims
Answer: B
Rationale: CMS defines abuse as involving payment for items or services when
there is no legal entitlement to that payment and the healthcare provider has not
knowingly or intentionally misrepresented facts to obtain payment.
Q3. Which of the following best describes "waste" in the Medicare context?
A) Intentional deception to gain something of value
B) Submitting claims for services not rendered
C) Overutilization of services resulting in unnecessary costs to the Medicare
program
D) Forging a beneficiary's signature on an enrollment form
,Answer: C
Rationale: CMS defines waste as the overutilization of services, or other practices
that directly or indirectly result in unnecessary costs to the Medicare program.
Waste is generally not criminally negligent but rather misuse of resources.
Q4. The key element distinguishing fraud from abuse is:
A) The amount of money involved
B) Whether the provider is a physician or other healthcare professional
C) The presence of intent to deceive or misrepresent
D) The number of beneficiaries affected
Answer: C
Rationale: Fraud requires knowingly and willfully executing a scheme to defraud,
involving intent to deceive. Abuse results in unwarranted payments without the
intent to deceive necessary for fraud.
Q5. Healthcare fraud can result in civil and criminal penalties that include:
A) Only fines and monetary damages
, B) Fines, monetary damages, and imprisonment
C) Only exclusion from Medicare
D) Only imprisonment for up to 5 years
Answer: B
Rationale: Healthcare fraud can result in civil and criminal penalties including
fines, monetary damages, and imprisonment (up to 20 years or life if death
results).
Q6. Which of the following is an example of provider abuse?
A) A physician deliberately billing for services not performed
B) A physician conducting tests viewed as unnecessary within the medical
community, believing them to be medically necessary
C) A beneficiary selling prescribed drugs to a crime ring
D) An agent forging a signature on an enrollment form
Answer: B
100% ACCURATE ANSWERS
SECTION 1: FUNDAMENTALS OF FRAUD, WASTE & ABUSE (Questions 1-35)
Q1. According to the healthcare fraud criminal statute, what penalties can be
imposed for defrauding a healthcare benefit program?
A) Only civil monetary penalties
B) Fines and up to 10 years in prison (or longer if death results)
C) Only exclusion from Medicare programs
D) Community service and probation only
Answer: B
Rationale: The criminal healthcare fraud statute (Section 1347 of Title 18) imposes
criminal penalties including fines and imprisonment of up to 10 years (or up to life
in prison if the violation resulted in a person's death).
,Q2. CMS defines "abuse" as:
A) Intentional deception to obtain something of value
B) Payment for items or services when there is no legal entitlement and the
provider has not knowingly misrepresented facts
C) Overutilization of services resulting in unnecessary costs to Medicare
D) Knowingly submitting false claims
Answer: B
Rationale: CMS defines abuse as involving payment for items or services when
there is no legal entitlement to that payment and the healthcare provider has not
knowingly or intentionally misrepresented facts to obtain payment.
Q3. Which of the following best describes "waste" in the Medicare context?
A) Intentional deception to gain something of value
B) Submitting claims for services not rendered
C) Overutilization of services resulting in unnecessary costs to the Medicare
program
D) Forging a beneficiary's signature on an enrollment form
,Answer: C
Rationale: CMS defines waste as the overutilization of services, or other practices
that directly or indirectly result in unnecessary costs to the Medicare program.
Waste is generally not criminally negligent but rather misuse of resources.
Q4. The key element distinguishing fraud from abuse is:
A) The amount of money involved
B) Whether the provider is a physician or other healthcare professional
C) The presence of intent to deceive or misrepresent
D) The number of beneficiaries affected
Answer: C
Rationale: Fraud requires knowingly and willfully executing a scheme to defraud,
involving intent to deceive. Abuse results in unwarranted payments without the
intent to deceive necessary for fraud.
Q5. Healthcare fraud can result in civil and criminal penalties that include:
A) Only fines and monetary damages
, B) Fines, monetary damages, and imprisonment
C) Only exclusion from Medicare
D) Only imprisonment for up to 5 years
Answer: B
Rationale: Healthcare fraud can result in civil and criminal penalties including
fines, monetary damages, and imprisonment (up to 20 years or life if death
results).
Q6. Which of the following is an example of provider abuse?
A) A physician deliberately billing for services not performed
B) A physician conducting tests viewed as unnecessary within the medical
community, believing them to be medically necessary
C) A beneficiary selling prescribed drugs to a crime ring
D) An agent forging a signature on an enrollment form
Answer: B
