2025 AHIP - FRAUD, WASTE, AND
ABUSE EXAM QUESTIONS &
VERIFIED CORRECT ANSWERS
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 purpose of payment. As part of this job, you use a process to verify the data is accurate.
Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk
diagnosis codes for certain individuals. 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 minor inventory discrepancy. What should you do? - correct answer ✔✔Follow your
pharmacy's procedures.
A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription
is for a controlled substance with a quantity of 160. This beneficiary normally receives a
quantity of 60, not 160. You review the prescription and have concerns about possible 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
ABUSE EXAM QUESTIONS &
VERIFIED CORRECT ANSWERS
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 purpose of payment. As part of this job, you use a process to verify the data is accurate.
Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk
diagnosis codes for certain individuals. 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 minor inventory discrepancy. What should you do? - correct answer ✔✔Follow your
pharmacy's procedures.
A person drops off a prescription for a beneficiary who is a "regular" customer. The prescription
is for a controlled substance with a quantity of 160. This beneficiary normally receives a
quantity of 60, not 160. You review the prescription and have concerns about possible 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
