AHIP FRAUD WASTE AND ABUSE EXAM 2025
WITH ACTUAL CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
|FREQUENTLY TESTED QUESTIONS AND
SOLUTIONS |ALREADY GRADED A+|BRAND
NEW!!|LATEST UPDATE |GUARANTEED PASS
vendor
one that sells or distributes goods or services
waste
unjustifiable use of funds, products, or services
whistle blower
in health care, a health care employee with inside knowledge of wrongdoing who reports it
can fraudulent activity be unintentional?
yes. it can also result from a lack of knowledge of proper billing or system-based verification procedures.
examples of fraud
-Providers bill incorrectly; make false claims about qualifications, licensure or education; alter
information on health care plans, prescriptions, and other medical documentation; prescribe
unnecessary treatments; use unlicensed personnel; or falsify the diagnosis or procedure to maximize
payments.
-Patients use someone else's health plan authorization card to obtain health care services, claim non-
covered dependents, participate in doctor shopping, forge prescriptions, sell prescription medications,
or agree to allow providers to submit claims for services they did not receive or need.
-Employees fabricate claims, submit false application data, or change a provider's address to intercept
provider payments.
-Organizations deliberately submit or receive undue monetary profit from health care benefit programs
by submitting incorrect claims for health care services or equipment.
1|Page
,what is misuse?
Misuse occurs when a provider renders health care services inappropriately, such as providing primary
health care services in an emergency department.
what is overuse?
Overuse refers to situations where a patient is unlikely to benefit from a service, or when a provider
prescribes a health care intervention even though it will not improve outcomes or quality of care.
what is underuse?
Underuse refers to the absence of health care services that might help prevent, detect, or treat a health
care problem early in its course. Underuse can occur due to lack of access to health care services and
can result in higher expenditures when complications arise or when it takes more costly procedures to
manage advanced stages of disease
what is the issue with durable equipment?
providers might submit claims for durable medical equipment, such as wheelchairs and orthotics, for
patients who do not want or need the equipment. Durable medical equipment suppliers have high
payment error rates and receive excessive reimbursement rates, and sometimes provide kickbacks to
providers who refer patients.
what should you include when reporting fraud to the HHS Commission's Office of Inspector General?
nature of complaint, names of individuals and/or entity involves, addresses, numbers,
medicare/medicaid #, other identifying info
for the person filing the fraud report, what should they do for themselves?
-Immediately cease filing the problematic bills.
-Seek knowledgeable legal counsel.
-Determine what money was collected in error from patients and from the federal health care programs
and report and return overpayments.
-Unwind the problematic investment.
-Disengage from the suspicious relationship.
-Consider using OIG's or CMS's self-disclosure protocols.
what does the whistle blower protection do?
a statute that entitles employees to reinstatement of their position, double back pay, compensation for
legal representation, and a commentary reward if the government recovers the funds
Which health care resources and services are most vulnerable to fraud, waste, and abuse?
In addition to vulnerabilities of fraud related to expenses for home care services, durable medical
equipment, outpatient infusions, and medications, there are other resources and services that
constitute waste. Examples are practicing "defensive medicine," such as when providers prescribe
diagnostic laboratory or imaging tests to protect against malpractice, performing expensive diagnostic
tests that do not affect the course of treatment, recommending costly procedures or surgery when
2|Page
,other less costly medical alternatives are sufficient, and providing intensive non-palliative end-of-life
care. Yet another source of waste is hospital admission for uncontrolled chronic diseases, such as
diabetes mellitus, when improving the quality of chronic disease management and access to care in
outpatient settings could minimize or eliminate hospitalizations.
Ways to report potential Fraud, Waste, and Abuse (FWA) include:
a. Telephone hotlines
b. Mail Drops
c. In-person reporting to the compliance department/supervisor
d. Special Investigations Units (SIUs)
e. All of the above
Once a corrective action plan is started, the corrective actions must be monitored annually to ensure
they are effective.
:
True False
false
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.
:
True False
true
These are examples of issues that should be reported to a Compliance Department: suspected Fraud,
Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee
misconduct.
:
True False
true
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.
:
True False
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.
3|Page
, :
True False
ACA Section 1557 differs from earlier legislation in providing broader protection against discrimination
based on
sex
Section 1557 of the Affordable Care Act applies to
all health programs and activities administered by or receiving federal financial assistance from HHS.
Under ACA Section 1557, prohibited actions involve
d. eligibility, claims, and marketing. Correct
Under ACA Section 1557, a person
c. cannot be discriminated against based on her legal or illegal immigration status or ability to speak
English. Correct
Under ACA Section 1557, a health plan
d. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free
of charge. Correct
Which of these actions is most likely to be permitted in dealing with a person with limited English
proficiency?
a. Allowing a child to interpret in an emergency. Correct
Under ACA Section 1557, sex discrimination includes a person's
c. sex, pregnancy, sex stereotypes, or gender identity. Correct
Under ACA Section 1557, a health plan sold through a state exchange may, based on an individual's age,
d. charge higher premiums. Correct
ACA Section 1557 rules for disability concern
d. Policies and procedures, physical access, and communication. Correct
Which area of potential discrimination is not generally covered by ACA Section 1557?
c. Employment (with the exception of the provision of health insurance). Correct
As a result of violations of ACA Section 1557 nondiscrimination rules,
c. a health plan may revoke an agent or broker's appointment with the health plan. Correct
For a health plan, what are the possible consequences of violations of ACA Section 1557?
b. Loss of federal business and compensatory damages. Correct
4|Page
WITH ACTUAL CORRECT QUESTIONS AND
VERIFIED DETAILED ANSWERS
|FREQUENTLY TESTED QUESTIONS AND
SOLUTIONS |ALREADY GRADED A+|BRAND
NEW!!|LATEST UPDATE |GUARANTEED PASS
vendor
one that sells or distributes goods or services
waste
unjustifiable use of funds, products, or services
whistle blower
in health care, a health care employee with inside knowledge of wrongdoing who reports it
can fraudulent activity be unintentional?
yes. it can also result from a lack of knowledge of proper billing or system-based verification procedures.
examples of fraud
-Providers bill incorrectly; make false claims about qualifications, licensure or education; alter
information on health care plans, prescriptions, and other medical documentation; prescribe
unnecessary treatments; use unlicensed personnel; or falsify the diagnosis or procedure to maximize
payments.
-Patients use someone else's health plan authorization card to obtain health care services, claim non-
covered dependents, participate in doctor shopping, forge prescriptions, sell prescription medications,
or agree to allow providers to submit claims for services they did not receive or need.
-Employees fabricate claims, submit false application data, or change a provider's address to intercept
provider payments.
-Organizations deliberately submit or receive undue monetary profit from health care benefit programs
by submitting incorrect claims for health care services or equipment.
1|Page
,what is misuse?
Misuse occurs when a provider renders health care services inappropriately, such as providing primary
health care services in an emergency department.
what is overuse?
Overuse refers to situations where a patient is unlikely to benefit from a service, or when a provider
prescribes a health care intervention even though it will not improve outcomes or quality of care.
what is underuse?
Underuse refers to the absence of health care services that might help prevent, detect, or treat a health
care problem early in its course. Underuse can occur due to lack of access to health care services and
can result in higher expenditures when complications arise or when it takes more costly procedures to
manage advanced stages of disease
what is the issue with durable equipment?
providers might submit claims for durable medical equipment, such as wheelchairs and orthotics, for
patients who do not want or need the equipment. Durable medical equipment suppliers have high
payment error rates and receive excessive reimbursement rates, and sometimes provide kickbacks to
providers who refer patients.
what should you include when reporting fraud to the HHS Commission's Office of Inspector General?
nature of complaint, names of individuals and/or entity involves, addresses, numbers,
medicare/medicaid #, other identifying info
for the person filing the fraud report, what should they do for themselves?
-Immediately cease filing the problematic bills.
-Seek knowledgeable legal counsel.
-Determine what money was collected in error from patients and from the federal health care programs
and report and return overpayments.
-Unwind the problematic investment.
-Disengage from the suspicious relationship.
-Consider using OIG's or CMS's self-disclosure protocols.
what does the whistle blower protection do?
a statute that entitles employees to reinstatement of their position, double back pay, compensation for
legal representation, and a commentary reward if the government recovers the funds
Which health care resources and services are most vulnerable to fraud, waste, and abuse?
In addition to vulnerabilities of fraud related to expenses for home care services, durable medical
equipment, outpatient infusions, and medications, there are other resources and services that
constitute waste. Examples are practicing "defensive medicine," such as when providers prescribe
diagnostic laboratory or imaging tests to protect against malpractice, performing expensive diagnostic
tests that do not affect the course of treatment, recommending costly procedures or surgery when
2|Page
,other less costly medical alternatives are sufficient, and providing intensive non-palliative end-of-life
care. Yet another source of waste is hospital admission for uncontrolled chronic diseases, such as
diabetes mellitus, when improving the quality of chronic disease management and access to care in
outpatient settings could minimize or eliminate hospitalizations.
Ways to report potential Fraud, Waste, and Abuse (FWA) include:
a. Telephone hotlines
b. Mail Drops
c. In-person reporting to the compliance department/supervisor
d. Special Investigations Units (SIUs)
e. All of the above
Once a corrective action plan is started, the corrective actions must be monitored annually to ensure
they are effective.
:
True False
false
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.
:
True False
true
These are examples of issues that should be reported to a Compliance Department: suspected Fraud,
Waste, and Abuse (FWA); potential health privacy violation, and unethical behavior/employee
misconduct.
:
True False
true
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.
:
True False
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.
3|Page
, :
True False
ACA Section 1557 differs from earlier legislation in providing broader protection against discrimination
based on
sex
Section 1557 of the Affordable Care Act applies to
all health programs and activities administered by or receiving federal financial assistance from HHS.
Under ACA Section 1557, prohibited actions involve
d. eligibility, claims, and marketing. Correct
Under ACA Section 1557, a person
c. cannot be discriminated against based on her legal or illegal immigration status or ability to speak
English. Correct
Under ACA Section 1557, a health plan
d. cannot deny coverage to LEP individuals and is required to provide language assistance to them, free
of charge. Correct
Which of these actions is most likely to be permitted in dealing with a person with limited English
proficiency?
a. Allowing a child to interpret in an emergency. Correct
Under ACA Section 1557, sex discrimination includes a person's
c. sex, pregnancy, sex stereotypes, or gender identity. Correct
Under ACA Section 1557, a health plan sold through a state exchange may, based on an individual's age,
d. charge higher premiums. Correct
ACA Section 1557 rules for disability concern
d. Policies and procedures, physical access, and communication. Correct
Which area of potential discrimination is not generally covered by ACA Section 1557?
c. Employment (with the exception of the provision of health insurance). Correct
As a result of violations of ACA Section 1557 nondiscrimination rules,
c. a health plan may revoke an agent or broker's appointment with the health plan. Correct
For a health plan, what are the possible consequences of violations of ACA Section 1557?
b. Loss of federal business and compensatory damages. Correct
4|Page
