1
UHC Ethics & Compliance Examination
2025/2026 | Actual Exam Questions with
Verified Answers & Rationales |
UnitedHealthcare Certification | Pass
Guarantee
PART I: MULTIPLE CHOICE QUESTIONS (80 Questions)
Section A: Fraud, Waste & Abuse Prevention (20 Questions)
1. Which of the following billing practices constitutes fraud under UHC policy?
• A. Billing for services not medically necessary
• B. Billing for services not documented in patient records
• C. Billing for services not actually provided
• D. All of the above
Answer: D. All of the above
Rationale: UHC defines fraud as intentionally submitting false information for
payment. This includes billing for services not provided, not documented, or not
medically necessary. All listed practices violate federal False Claims Act and UHC
compliance standards.
2. The UHC Healthcare Fraud Tip Line number is:
• A. 1-800-455-4521
• B. 1-866-242-7727
• C. 1-952-936-7463
• D. 1-800-MEDICARE
Answer: B. 1-866-242-7727
Rationale: Per UHC 2025 policy, the dedicated Healthcare Fraud Tip Line is 1 -
, 2
866-242-7727. The Compliance & Ethics HelpCenter is 1-800-455-4521, while 1-
952-936-7463 reaches the Ethics Office.
3. Which detection method does UHC use to identify potential fraud
prospectively?
• A. Post-payment data analytics
• B. Pre-payment data analytics
• C. Provider self-reporting
• D. Patient complaints only
Answer: B. Pre-payment data analytics
Rationale: UHC employs both prospective (pre-payment) and retrospective (post-
payment) detection methods. Pre-payment data analytics catch suspicious patterns
before claims are paid, while post-payment analytics identify issues after payment.
4. Under the Beneficiary Inducement Law, providers cannot:
• A. Offer gifts to influence member selection
• B. Provide free transportation to appointments
• C. Waive copayments for low-income patients
• D. Offer health education materials
Answer: A. Offer gifts to influence member selection
Rationale: The federal Beneficiary Inducement Law prohibits offering money or
services likely to influence members to select specific providers. This includes
gifts, payments, or other inducements for consultations or treatments.
5. UHC's compliance program includes how many core elements?
• A. 5
• B. 6
• C. 7
• D. 8
Answer: C. 7
Rationale: UHC's compliance program incorporates the 7 elements required by
, 3
U.S. Sentencing Guidelines: oversight, standards/policies, training,
communication, enforcement, monitoring, and response to violations.
6. Which of the following is NOT considered waste under UHC definitions?
• A. Overuse of services
• B. Inefficient care delivery
• C. Intentional billing errors
• D. Unnecessary administrative costs
Answer: C. Intentional billing errors
Rationale: Waste refers to overuse or inefficient use of resources, while fraud
involves intentional deception. Intentional billing errors constitute fraud, not waste.
7. Corrective Action Plans (CAPs) are implemented when:
• A. Providers achieve high quality scores
• B. Providers comply with all billing guidelines
• C. Providers demonstrate billing/performance problems
• D. Providers request additional training
Answer: C. Providers demonstrate billing/performance problems
Rationale: UHC initiates CAPs when providers fail to comply with billing
guidelines or performance standards. These plans include monitoring and
education to address identified issues.
8. The False Claims Act protects whistleblowers from:
• A. Harassment only
• B. Demotion and wrongful termination
• C. Retaliation including harassment, demotion, and termination
• D. No protection exists
Answer: C. Retaliation including harassment, demotion, and termination
Rationale: The False Claims Act provides comprehensive protection against
retaliation for good-faith reporting, including harassment, demotion, wrongful
termination, and other adverse actions.
9. UHC's automated policy enforcement for laboratory claims begins:
, 4
• A. January 1, 2025
• B. December 1, 2025
• C. June 1, 2026
• D. October 1, 2026
Answer: B. December 1, 2025
Rationale: Per UHC's September 2025 Reimbursement Policy Update, automated
post-service, pre-payment policy enforcement for laboratory claims takes effect
December 1, 2025.
10. Which federal agency oversees Medicare compliance for UHC?
• A. FDA
• B. DEA
• C. CMS
• D. FBI
Answer: C. CMS
Rationale: The Centers for Medicare & Medicaid Services (CMS) administers
Medicare and contracts with private companies like UHC to offer Medicare
Advantage plans, overseeing all compliance requirements.
11. Medical identity theft involves:
• A. Stealing patient's insurance information for fraudulent billing
• B. Physical theft of medical records
• C. Identity theft for employment purposes
• D. Credit card fraud in medical offices
Answer: A. Stealing patient's insurance information for fraudulent billing
Rationale: Medical identity theft specifically involves using someone else's
insurance information or Medicare number to obtain medical services or submit
fraudulent claims.
12. UHC requires exclusion checks to be performed:
• A. Monthly
UHC Ethics & Compliance Examination
2025/2026 | Actual Exam Questions with
Verified Answers & Rationales |
UnitedHealthcare Certification | Pass
Guarantee
PART I: MULTIPLE CHOICE QUESTIONS (80 Questions)
Section A: Fraud, Waste & Abuse Prevention (20 Questions)
1. Which of the following billing practices constitutes fraud under UHC policy?
• A. Billing for services not medically necessary
• B. Billing for services not documented in patient records
• C. Billing for services not actually provided
• D. All of the above
Answer: D. All of the above
Rationale: UHC defines fraud as intentionally submitting false information for
payment. This includes billing for services not provided, not documented, or not
medically necessary. All listed practices violate federal False Claims Act and UHC
compliance standards.
2. The UHC Healthcare Fraud Tip Line number is:
• A. 1-800-455-4521
• B. 1-866-242-7727
• C. 1-952-936-7463
• D. 1-800-MEDICARE
Answer: B. 1-866-242-7727
Rationale: Per UHC 2025 policy, the dedicated Healthcare Fraud Tip Line is 1 -
, 2
866-242-7727. The Compliance & Ethics HelpCenter is 1-800-455-4521, while 1-
952-936-7463 reaches the Ethics Office.
3. Which detection method does UHC use to identify potential fraud
prospectively?
• A. Post-payment data analytics
• B. Pre-payment data analytics
• C. Provider self-reporting
• D. Patient complaints only
Answer: B. Pre-payment data analytics
Rationale: UHC employs both prospective (pre-payment) and retrospective (post-
payment) detection methods. Pre-payment data analytics catch suspicious patterns
before claims are paid, while post-payment analytics identify issues after payment.
4. Under the Beneficiary Inducement Law, providers cannot:
• A. Offer gifts to influence member selection
• B. Provide free transportation to appointments
• C. Waive copayments for low-income patients
• D. Offer health education materials
Answer: A. Offer gifts to influence member selection
Rationale: The federal Beneficiary Inducement Law prohibits offering money or
services likely to influence members to select specific providers. This includes
gifts, payments, or other inducements for consultations or treatments.
5. UHC's compliance program includes how many core elements?
• A. 5
• B. 6
• C. 7
• D. 8
Answer: C. 7
Rationale: UHC's compliance program incorporates the 7 elements required by
, 3
U.S. Sentencing Guidelines: oversight, standards/policies, training,
communication, enforcement, monitoring, and response to violations.
6. Which of the following is NOT considered waste under UHC definitions?
• A. Overuse of services
• B. Inefficient care delivery
• C. Intentional billing errors
• D. Unnecessary administrative costs
Answer: C. Intentional billing errors
Rationale: Waste refers to overuse or inefficient use of resources, while fraud
involves intentional deception. Intentional billing errors constitute fraud, not waste.
7. Corrective Action Plans (CAPs) are implemented when:
• A. Providers achieve high quality scores
• B. Providers comply with all billing guidelines
• C. Providers demonstrate billing/performance problems
• D. Providers request additional training
Answer: C. Providers demonstrate billing/performance problems
Rationale: UHC initiates CAPs when providers fail to comply with billing
guidelines or performance standards. These plans include monitoring and
education to address identified issues.
8. The False Claims Act protects whistleblowers from:
• A. Harassment only
• B. Demotion and wrongful termination
• C. Retaliation including harassment, demotion, and termination
• D. No protection exists
Answer: C. Retaliation including harassment, demotion, and termination
Rationale: The False Claims Act provides comprehensive protection against
retaliation for good-faith reporting, including harassment, demotion, wrongful
termination, and other adverse actions.
9. UHC's automated policy enforcement for laboratory claims begins:
, 4
• A. January 1, 2025
• B. December 1, 2025
• C. June 1, 2026
• D. October 1, 2026
Answer: B. December 1, 2025
Rationale: Per UHC's September 2025 Reimbursement Policy Update, automated
post-service, pre-payment policy enforcement for laboratory claims takes effect
December 1, 2025.
10. Which federal agency oversees Medicare compliance for UHC?
• A. FDA
• B. DEA
• C. CMS
• D. FBI
Answer: C. CMS
Rationale: The Centers for Medicare & Medicaid Services (CMS) administers
Medicare and contracts with private companies like UHC to offer Medicare
Advantage plans, overseeing all compliance requirements.
11. Medical identity theft involves:
• A. Stealing patient's insurance information for fraudulent billing
• B. Physical theft of medical records
• C. Identity theft for employment purposes
• D. Credit card fraud in medical offices
Answer: A. Stealing patient's insurance information for fraudulent billing
Rationale: Medical identity theft specifically involves using someone else's
insurance information or Medicare number to obtain medical services or submit
fraudulent claims.
12. UHC requires exclusion checks to be performed:
• A. Monthly
