2025 AHIP - Fraud, Waste, and Abuse
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - ANS 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? -
ANS 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)? - ANS Deportation
You are performing a regular inventory of the controlled substances in the pharmacy.
You discover a minor inventory discrepancy. What should you do? - ANS 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? - ANS 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? - ANS Consult with your
immediate supervisor for next steps or contact the compliance department (via
compliance hotline, Special Investigations Unit [SIU], or other mechanism)
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. - ANS True
Which of the following requires intent to obtain payment and the knowledge the actions
are wrong? - ANS 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? -
ANS 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)? - ANS Deportation
You are performing a regular inventory of the controlled substances in the pharmacy.
You discover a minor inventory discrepancy. What should you do? - ANS 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? - ANS 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? - ANS Consult with your
immediate supervisor for next steps or contact the compliance department (via
compliance hotline, Special Investigations Unit [SIU], or other mechanism)
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. - ANS True
