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