2025/2026 AHIP - FRAUD, WASTE, AND
ABUSE WITH CORRECT
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - 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? -
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)? - 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? - 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? - ANSWER-Call the prescriber
to verify the quantity
What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? -
ANSWER-All of the above
Abuse involves payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly or intentionally misrepresented facts to
obtain payment. - ANSWER-True
Waste includes any misuse of resources, such as the overuse of services or other
practices that directly or indirectly result in unnecessary costs to the Medicare Program.
- ANSWER-True
Any person who knowingly submits false claims to the Government is liable for five
times the Government's damages caused by the violator plus a penalty. - ANSWER-
False
ABUSE WITH CORRECT
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - 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? -
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)? - 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? - 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? - ANSWER-Call the prescriber
to verify the quantity
What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? -
ANSWER-All of the above
Abuse involves payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly or intentionally misrepresented facts to
obtain payment. - ANSWER-True
Waste includes any misuse of resources, such as the overuse of services or other
practices that directly or indirectly result in unnecessary costs to the Medicare Program.
- ANSWER-True
Any person who knowingly submits false claims to the Government is liable for five
times the Government's damages caused by the violator plus a penalty. - ANSWER-
False
