AHIP Fraud Waste & Abuse Questions And Answers
Which of the following requires intent to obtain payment and the
knowledge that the actions are wrong? - ANSWER -Fraud
Which of the following is not potentially a penalty for violation of
the law or regulation prohibiting fraud, waste and abuse (fwa)? -
ANSWER -Deportation
A person comes into your pharmacy to drop 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 the possible
forgery. What is your next step? - ANSWER -Call the
prescriber to verify the quantity
Your job is to submit risk diagnosis to the centers for Medicare
& medicaid services (cms) for the purpose of payment. As part
of this job you verify, through a certain process, that the data is
accurate. Your immediate supervisor tells you to ignore the
sponsors process and to adjust/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)
You are in charge of payment of 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 certain procedure. You
review the same type of procedure for other diagnostic
providers and realize that doe diagnostics' claim far exceed any
other provider that you reviewed. What should you do? -
ANSWER -Consult with your immediate supervisor for the
next steps or contact the compliance department (via
compliance hotline, special investigation unit (siu), or other
mechanism)
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 pharmacys procedures
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Which of the following requires intent to obtain payment and the
knowledge that the actions are wrong? - ANSWER -Fraud
Which of the following is not potentially a penalty for violation of
the law or regulation prohibiting fraud, waste and abuse (fwa)? -
ANSWER -Deportation
A person comes into your pharmacy to drop 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 the possible
forgery. What is your next step? - ANSWER -Call the
prescriber to verify the quantity
Your job is to submit risk diagnosis to the centers for Medicare
& medicaid services (cms) for the purpose of payment. As part
of this job you verify, through a certain process, that the data is
accurate. Your immediate supervisor tells you to ignore the
sponsors process and to adjust/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)
You are in charge of payment of 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 certain procedure. You
review the same type of procedure for other diagnostic
providers and realize that doe diagnostics' claim far exceed any
other provider that you reviewed. What should you do? -
ANSWER -Consult with your immediate supervisor for the
next steps or contact the compliance department (via
compliance hotline, special investigation unit (siu), or other
mechanism)
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 pharmacys procedures
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