AHIP (AMERICAN HEALTH INSURANCE PLANS) FRAUD ,WASTE AND ABUSE: 2023 EXAM GUIDING QUESTIONS ANS ANSWERS

How to recognize FWA in the Medicare Program - Knowledge of the law including the Civil False claims Act, Health Care Fraud Statute, and Criminal Fraud, Anti-Kickback Statute, Stark Statute, Exclusion from all Federal healthcare programs, and the Health Insurance Portability and Accountability Act. Civil False Claims Act - Makes a person liable to pay damages to the government if 1. He or she knowingly conspires to commit FWA. 2. Carries out other acts to obtain property from the government by misrepresentation. 3. Conceals or improperly avoids or decreases an obligation to pay the government. 4. Makes or uses a false record or statement supporting a false claim. 5. Presents a false claim for payment or approval. Health Care Fraud statute - "Whoever knowingly and willfully executes, or attempts to execute, a scheme or artifice of defraud any healthcare benefit program...shall be fined under this title or imprisoned not more than 10 years, or both." Criminal Fraud - Persons who knowingly make a false claim may be subject to criminal fines up to $250,000 and imprisonment for up to 20 years. Anti-Kickback Statute - The Anti-Kickback statute prohibits knowingly and willfully soliciting, receiving, offering, or paying remuneration (including any kickback, bribe, or rebate) for referrals for services that are paid, in whole or in part, under the Federal health care program (including the Medicare Program). Stark Statute - Prohibits a physician from making referrals for certain designated health services to an entity when the physician (or member or his or her family) has an ownership/investment interest or a compensation arrangement. Exclusion - The Office of Inspector General (OIG) can exclude individuals or entities from federally funded healthcare programs and maintains a list of them. HIPPA - Safeguards deter unauthorized access to PHI. Potential consequences and penalties associated with violations - Fines and imprisonment. Methods of preventing FWA - 1. Look for suspicious activity. 2. Conduct yourself in and ethical manner.