2024 Medicare+ Fraud, Waste, and
Abuse
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)
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.
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - answer Fraud
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 perscriber
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)
Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting fraud, waste, and abuse (FWA)? - answer Deportation
Abuse
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)
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.
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - answer Fraud
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 perscriber
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)
Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting fraud, waste, and abuse (FWA)? - answer Deportation
