2025 AHIP - Fraud, Waste, and Abuse
Fraud
Which of the following requires intent to obtain payment and the knowledge the actions are wrong?
Report the incident to the compliance department (via compliance hotline 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?
Deportation
Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud,
waste, and abuse (FWA)?
Follow your pharmacy's procedures.
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a
minor inventory discrepancy. What should you do?
Call the prescriber to verify the quantity
1
https:// /ahip-4-ahip-2024-module-4-flash-cards/
, 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?
Consult with your immediate supervisor for next steps or contact the compliance department (via
compliance hotline, Special Investigations Unit [SIU], or other mechanism)
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?
True
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which
includes Medicare) constitute fraud by the person making as well as the person receiving them.
True
Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health
Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the Anti-Kickback
Statute, and the Criminal Health Care Fraud Statute.
True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
2
https:// /ahip-4-ahip-2024-module-4-flash-cards/
Fraud
Which of the following requires intent to obtain payment and the knowledge the actions are wrong?
Report the incident to the compliance department (via compliance hotline 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?
Deportation
Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud,
waste, and abuse (FWA)?
Follow your pharmacy's procedures.
You are performing a regular inventory of the controlled substances in the pharmacy. You discover a
minor inventory discrepancy. What should you do?
Call the prescriber to verify the quantity
1
https:// /ahip-4-ahip-2024-module-4-flash-cards/
, 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?
Consult with your immediate supervisor for next steps or contact the compliance department (via
compliance hotline, Special Investigations Unit [SIU], or other mechanism)
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?
True
Bribes or kickbacks of any kind for services that are paid under a Federal health care program (which
includes Medicare) constitute fraud by the person making as well as the person receiving them.
True
Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the Health
Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the Anti-Kickback
Statute, and the Criminal Health Care Fraud Statute.
True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
2
https:// /ahip-4-ahip-2024-module-4-flash-cards/
