FRAUD, WASTE, AND ABUSE Questions and Answers with complete solution

ACA Section 1557, and the Final Rule interpreting it as drafted by the Obama Administration, differs from earlier legislation in providing broader protection against discrimination based on - sex. Under ACA Section 1557, a health plan sold through a state exchange may, based on an individual's age - charge higher premiums ACA Section 1557 rules for disability concern - Policies and procedures, physical access, and communication As a result of violations of ACA Section 1557 nondiscrimination rules, - a health plan may revoke an agent or broker's appointment with the health plan Which Medicare programs are covered by ACA Section 1557? - Parts A, C, and D, but not B 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 number of members. 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? - Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) 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? - Report the incident to the compliance department (via compliance hotline or other mechanism) 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? - Call the prescriber to verify the quantityWhich of the following requires intent to obtain payment and the knowledge the actions are wrong? - Fraud Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)? - Deportation You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? - Discuss your concerns with your supervis