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AHIP TRAINING MEDICARE FRAUD, WASTE,
AND ABUSE TRAINING EXAM | ACTUAL
QUESTIONS WITH VERIFIED SOLUTIONS
FWA Involving Medicare Plan Sponsors - correct-answer ---The amt. MA plan
enrollees must pay for certain services is greater than what the sponsor's
literature implies.
--An MA plan realizes it had been overpaid by the Medicare program but fails to
report it to the CMS
--An MA plan fails to disenroll an enrollee (and continues receiving payment for
the enrollee) even though it knows the enrollee has permanently moved from the
plan service area.
Summarizing the Importance of FWA Detection, Correction, and Prevention -
correct-answer -**Most providers, supplies, pharmacists, and sale
representatives who work with Medicare are honest and seek to do the right
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thing. But there are a few individuals and organizations that knowingly commit
fraud, while others engage in practices that result in waste or abuse.
**CMS and Medicare plan sponsors are committed to providing quality
healthcare services to Medicare beneficiaries while reducing the costs of fraud,
waste and abuse. These costs take the form of not only lost dollars, but also of a
negative impact on the quality of life of Medicare beneficiaries. Fraud, waste, and
abuse can inflict real physical and emotional harm.
**This training has been designed to provide you with tools you need to
participate in the ongoing efforts against fraud, waste and abuse.
AUDIT - correct-answer -**A methodical examination and review of data or
processes with the purpose of verifying the data's accuracy or whether
established processes are in place or are properly followed.
Civil monetary penalties CMP's - correct-answer -Penalties that may be imposed
for a variety of conduct including Medicare FWA. Different amts. of penalties and
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assessments may be authorized based on the type of violation and can range as
high as $50,000 per violation.
Example: Presenting a claim that a person knows or should know is for a service
that was NOT provided as claimed or is false and fraudulent.
Pharmacy benefits manager - correct-answer -**A company that administers the
prescription drug benefit program of a health plan or employer.
**PBMs process and pay prescription drug claims and are often responsible for
creating and updating formularies.
**PBMs buy medications in large quantities from drug manufacturers and are
therefore able to obtain and offer discounts.
Special investigation unit - correct-answer -**A unit of a health plan (often
separate from the compliance office) dedicated to combating FWA.
**It is frequently staffed by former law enforcement personnel, such as veterans
of the FBI.
AHIP TRAINING MEDICARE FRAUD, WASTE,
AND ABUSE TRAINING EXAM | ACTUAL
QUESTIONS WITH VERIFIED SOLUTIONS
FWA Involving Medicare Plan Sponsors - correct-answer ---The amt. MA plan
enrollees must pay for certain services is greater than what the sponsor's
literature implies.
--An MA plan realizes it had been overpaid by the Medicare program but fails to
report it to the CMS
--An MA plan fails to disenroll an enrollee (and continues receiving payment for
the enrollee) even though it knows the enrollee has permanently moved from the
plan service area.
Summarizing the Importance of FWA Detection, Correction, and Prevention -
correct-answer -**Most providers, supplies, pharmacists, and sale
representatives who work with Medicare are honest and seek to do the right
,2|Page
thing. But there are a few individuals and organizations that knowingly commit
fraud, while others engage in practices that result in waste or abuse.
**CMS and Medicare plan sponsors are committed to providing quality
healthcare services to Medicare beneficiaries while reducing the costs of fraud,
waste and abuse. These costs take the form of not only lost dollars, but also of a
negative impact on the quality of life of Medicare beneficiaries. Fraud, waste, and
abuse can inflict real physical and emotional harm.
**This training has been designed to provide you with tools you need to
participate in the ongoing efforts against fraud, waste and abuse.
AUDIT - correct-answer -**A methodical examination and review of data or
processes with the purpose of verifying the data's accuracy or whether
established processes are in place or are properly followed.
Civil monetary penalties CMP's - correct-answer -Penalties that may be imposed
for a variety of conduct including Medicare FWA. Different amts. of penalties and
, 3|Page
assessments may be authorized based on the type of violation and can range as
high as $50,000 per violation.
Example: Presenting a claim that a person knows or should know is for a service
that was NOT provided as claimed or is false and fraudulent.
Pharmacy benefits manager - correct-answer -**A company that administers the
prescription drug benefit program of a health plan or employer.
**PBMs process and pay prescription drug claims and are often responsible for
creating and updating formularies.
**PBMs buy medications in large quantities from drug manufacturers and are
therefore able to obtain and offer discounts.
Special investigation unit - correct-answer -**A unit of a health plan (often
separate from the compliance office) dedicated to combating FWA.
**It is frequently staffed by former law enforcement personnel, such as veterans
of the FBI.
