2025 AHIP - Fraud, Waste, and Abuse
Exam with Questions and Correct
Answers 2025
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 ,for ,next ,steps ,or
Exam with Questions and Correct
Answers 2025
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 ,for ,next ,steps ,or
