AHIP TRAINING Medicare Fraud, Waste, and
Abuse Training 2022/2023 100% Answered
Medicare plan means - ANSWER A MA plan, MA-PD plan or PDP
Subcontractor means - ANSWER **An individual or entity that provides services on
behalf of a Medicare plan sponsor. This includes individuals and organizations with
DIRECT relationship with the plan sponsor or individuals or organizations with
INDIRECT relationship, such as an agent who has a contract with an agency or filed
marketing organization that contract with a Medicare plan.
FWA Training: A compliance program component - ANSWER **ALL Medicare plans are
required to have robust programs to assure compliance by plan employees an
subcontractor with all applicable laws, regulations and program guidance.
**One required component of a compliance program is a FWA program to identify and
address issues of compliance with FWA.
**It is important to remember that ALL Medicare plan sponsor employees and
subcontractors are responsible for complying with all relevant Medicare requirements,
even if lack of compliance may not be viewed as FWA,
FWA: Why participate in the training - ANSWER **Fraud, waste and abuse impacts
everyone who receives or relies on healthcare in the US.
**The purpose of this training is to help you detect, correct and prevent FWA and your
help is needed. You are part of the solution!
**As a subcontractor to or an employee of a Medicare plan, you are required to
participate in FWA training.
FWA: Combating: A federal priority - ANSWER **Important priority for the Federal
Government.
**CMS, the Federal agency responsible for administering these programs, takes its role
in leading anti-fraud efforts very seriously and has issued strict requirements for those
involved in providing MA and Medicare Part D coverage.
**The office of Inspector General, a sister agency to CMS within the US Department of
Health and Human Services , is also actively involved in anti-fraud efforts.
Steps by Medicare plans to Combat FWA - ANSWER --The establishment and
operation of special investigation units (SIU) or other existing departments that perform
an internal investigation function
--The analysis of claims data
--Collaboration with law enforcement agencies
--Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud,
waste and abuse.
CMS Anti-FWA requirements for Medicare plans - ANSWER --Actively seek to prevent
fraud, waste and abuse
, --Detect and investigate suspected FWA
--Implement corrective action when instances of FWA are uncovered
--Have a system in place 24 hrs per day for employees and subcontractors to
voluntarily, and confidentially report suspected FWA or misconduct related to the MA
and Part D programs
CMS FWA training requirements for a Sponsor's Employees - ANSWER **CMS
requires Medicare plan sponsors to provide training in FWA to their employees involved
in Medicare plan work.
**This training must occur within 90 days of hire and annually thereafter.
CMS FWA training requirements: Agents, Brokers and other Subcontractors - ANSWER
**The FWA training must be received not only by Medicare plan sponsor employees but
also by subcontractors and their employees who are under contract to provide health or
administrative services. The EXCEPTIONS are limited to:
***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS)
***Healthcare providers who are enrolled in Medicare Part A/B
CMS FWA training requirements: Agents, Brokers and other Subcontractors
Those required to take the training including, but not limited to: - ANSWER --Insurance
agents, brokers as well as employees of agencies and field marketing organizations that
are performing services for Medicare plans
--Employees of other vendors and subcontractors (such as claim processing firms)
--Pharmacies and employees of Pharmacy benefit Managers
FWA Definitions and examples - ANSWER FRAUD is an intentional act of deception,
misrepresentation, or concealment in order to gain something of value. Fraud often
involves criminal behavior.
ABUSE results in unwarranted payments from or costs to a Federal healthcare
consumer, provider, or other person obtains money to which they are not entitled, but
there is not the intent to deceive that is necessary for fraud to have occurred. Abuse
often involves actions which are inconsistent with accepted medical and/or business
practices.
WASTE occurs when poor or inefficient practices result in unnecessary healthcare
expenditures to a Government program.
Who Commits Medicare FWA? - ANSWER 1. Medicare beneficiaries
2. Physicians and other healthcare providers
3. Pharmacies, pharmacists, and pharmaceutical manufacturers and wholesalers
4. Health plan employees
5. Insurance agents and brokers
6. parties who neither provide not receive healthcare (professional criminals, including
members of organized crime)
7. Combinations of the above working together in collusion.
Abuse Training 2022/2023 100% Answered
Medicare plan means - ANSWER A MA plan, MA-PD plan or PDP
Subcontractor means - ANSWER **An individual or entity that provides services on
behalf of a Medicare plan sponsor. This includes individuals and organizations with
DIRECT relationship with the plan sponsor or individuals or organizations with
INDIRECT relationship, such as an agent who has a contract with an agency or filed
marketing organization that contract with a Medicare plan.
FWA Training: A compliance program component - ANSWER **ALL Medicare plans are
required to have robust programs to assure compliance by plan employees an
subcontractor with all applicable laws, regulations and program guidance.
**One required component of a compliance program is a FWA program to identify and
address issues of compliance with FWA.
**It is important to remember that ALL Medicare plan sponsor employees and
subcontractors are responsible for complying with all relevant Medicare requirements,
even if lack of compliance may not be viewed as FWA,
FWA: Why participate in the training - ANSWER **Fraud, waste and abuse impacts
everyone who receives or relies on healthcare in the US.
**The purpose of this training is to help you detect, correct and prevent FWA and your
help is needed. You are part of the solution!
**As a subcontractor to or an employee of a Medicare plan, you are required to
participate in FWA training.
FWA: Combating: A federal priority - ANSWER **Important priority for the Federal
Government.
**CMS, the Federal agency responsible for administering these programs, takes its role
in leading anti-fraud efforts very seriously and has issued strict requirements for those
involved in providing MA and Medicare Part D coverage.
**The office of Inspector General, a sister agency to CMS within the US Department of
Health and Human Services , is also actively involved in anti-fraud efforts.
Steps by Medicare plans to Combat FWA - ANSWER --The establishment and
operation of special investigation units (SIU) or other existing departments that perform
an internal investigation function
--The analysis of claims data
--Collaboration with law enforcement agencies
--Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud,
waste and abuse.
CMS Anti-FWA requirements for Medicare plans - ANSWER --Actively seek to prevent
fraud, waste and abuse
, --Detect and investigate suspected FWA
--Implement corrective action when instances of FWA are uncovered
--Have a system in place 24 hrs per day for employees and subcontractors to
voluntarily, and confidentially report suspected FWA or misconduct related to the MA
and Part D programs
CMS FWA training requirements for a Sponsor's Employees - ANSWER **CMS
requires Medicare plan sponsors to provide training in FWA to their employees involved
in Medicare plan work.
**This training must occur within 90 days of hire and annually thereafter.
CMS FWA training requirements: Agents, Brokers and other Subcontractors - ANSWER
**The FWA training must be received not only by Medicare plan sponsor employees but
also by subcontractors and their employees who are under contract to provide health or
administrative services. The EXCEPTIONS are limited to:
***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS)
***Healthcare providers who are enrolled in Medicare Part A/B
CMS FWA training requirements: Agents, Brokers and other Subcontractors
Those required to take the training including, but not limited to: - ANSWER --Insurance
agents, brokers as well as employees of agencies and field marketing organizations that
are performing services for Medicare plans
--Employees of other vendors and subcontractors (such as claim processing firms)
--Pharmacies and employees of Pharmacy benefit Managers
FWA Definitions and examples - ANSWER FRAUD is an intentional act of deception,
misrepresentation, or concealment in order to gain something of value. Fraud often
involves criminal behavior.
ABUSE results in unwarranted payments from or costs to a Federal healthcare
consumer, provider, or other person obtains money to which they are not entitled, but
there is not the intent to deceive that is necessary for fraud to have occurred. Abuse
often involves actions which are inconsistent with accepted medical and/or business
practices.
WASTE occurs when poor or inefficient practices result in unnecessary healthcare
expenditures to a Government program.
Who Commits Medicare FWA? - ANSWER 1. Medicare beneficiaries
2. Physicians and other healthcare providers
3. Pharmacies, pharmacists, and pharmaceutical manufacturers and wholesalers
4. Health plan employees
5. Insurance agents and brokers
6. parties who neither provide not receive healthcare (professional criminals, including
members of organized crime)
7. Combinations of the above working together in collusion.
