2025-2026 AHIP - FRAUD, WASTE, AND
ABUSE (QUESTIONS WITH VERIFIED
ANSWERS GRADED A+)
Which of the following requires intent to obtain payment and the knowledge the actions are wrong? -
correct answer-Fraud
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purp
ose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate sup
ervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain indi
viduals. What should you do? - correct answer-
Report the incident to the compliance department (via compliance hotline 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)? - correct answer-Deportation
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a min
or inventory discrepancy. What should you do? - correct answer-Follow your pharmacy's procedures.
AKperson drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a c
ontrolled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160.
You review the prescription and have concerns aboutKpossible forgery. What is your next step? -
correct answer-Call the prescriber 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? - correct answer-
Consult with your immediate supervisor for next stepsKor contact the compliance department (via compl
iance hotline, Special Investigations Unit [SIU], or other mechanism)
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which incl
udes Medicare) constitute fraud by the person making as well as the person receiving them. -
correct answer-True
ABUSE (QUESTIONS WITH VERIFIED
ANSWERS GRADED A+)
Which of the following requires intent to obtain payment and the knowledge the actions are wrong? -
correct answer-Fraud
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS) for the purp
ose of payment. As part of this job, you use a process to verify the data is accurate. Your immediate sup
ervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain indi
viduals. What should you do? - correct answer-
Report the incident to the compliance department (via compliance hotline 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)? - correct answer-Deportation
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a min
or inventory discrepancy. What should you do? - correct answer-Follow your pharmacy's procedures.
AKperson drops off a prescription for a beneficiary who is a "regular" customer. The prescription is for a c
ontrolled substance with a quantity of 160. This beneficiary normally receives a quantity of 60, not 160.
You review the prescription and have concerns aboutKpossible forgery. What is your next step? -
correct answer-Call the prescriber 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? - correct answer-
Consult with your immediate supervisor for next stepsKor contact the compliance department (via compl
iance hotline, Special Investigations Unit [SIU], or other mechanism)
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which incl
udes Medicare) constitute fraud by the person making as well as the person receiving them. -
correct answer-True
