AHIP - Discrimination, Fraud, Waste, &
Abuse – 44 questions, AHIP - Modules 1-
5, 105 complete questions and AHIP final
exam-50 verified questions
Under ACA Section 1557, a health plan premium sold through a state exchange
may, based on an individual's age and - ANS-charge higher premiums.
As a result of violations of ACA Section 1557 nondiscrimination rules, - ANS-a
health plan may revoke an agent or broker's appointment with the health plan.
ACA Section 1557 rules for disability concern - ANS-policies and procedures,
physical access, and communication.
Which Medicare programs are covered by ACA Section 1557 under the Biden
Administration's Final Rule (2024)? - ANS-Parts A, C, and D, and Part B.
Which of the following statements best describes Section 1557 of the Affordable
Care Act (ACA)? - ANS-Section 1557 incorporates earlier civil rights protections in
regard to race, color, national origin, disability, age and sex.
Section 1557 of the Affordable Care Act applies to - ANS-all health programs and
activities administered by or receiving federal financial assistance from HHS.
Which of the following would be considered permissible under Section 1557? - ANS-
Broker Mary Jones has recruited a diverse workforce. She encourages her agents to
prospect through community-based marketing and within their community of
influence.
,Which of these actions is most likely to be permitted in dealing with a person with
limited English proficiency? - ANS-Allowing a child to interpret in an emergency.
Which of the following statements best describes the scope of operations subject to
Section 1557 under the Final Rule (2024) of the Biden Administration? - ANS-
Entities principally engaged in health care, which includes health insurers, must
comply with Section 1557 for all programs they offer.
For a health plan, what are the possible consequences of violations of ACA Section
1557? - ANS-Loss of federal business and compensatory damages.
Auxiliary aids and services must be provided to individuals with disabilities, such
as those suffering from vision or hearing impairments, free of charge, and in a
timely manner. Auxiliary aids and services include which of the following:
I. large print materials
II. qualified sign language interpreters
III. braille materials and displays
IV. screen reader software - ANS-I, II, III, and IV
Under ACA Section 1557, a health plan - ANS-cannot deny coverage to LEP
individuals and is required to provide language assistance to them, free of charge.
Under Section 1557, the 2020 Final Rule issued during the Trump Administration
sex was initially defined____________ - ANS-as biologic sex only, meaning whether a
person was determined to be male or female at birth.
Which entity enforces Section 1557 for programs that receive funding from and are
administered by HHS? - ANS-The Office of Civil Rights (OCR) of HHS.
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
Which of the following requires intent to obtain payment and the knowledge the
actions are wrong? - ANS-Fraud
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)
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
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. - ANS-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. - ANS-True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
Conduct yourself in an ethical manner
Ensure accurate and timely data and billing
Ensure you coordinate with other payers
Keep up to date with FWA policies and procedures, standards of conduct, laws,
regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance
Verify all information provided to you - ANS-True
What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? -
ANS-All of the above
These are examples of issues that should be reported to a Compliance Department:
suspected fraud, waste, and abuse (FWA); potential health privacy violation,
unethical behavior, and employee misconduct. - ANS-True
Once a corrective action plan is started, the corrective action plan must be
monitored annually to ensure they are effective. - ANS-False
, 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. - ANS-False
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
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. - ANS-True
Ways to report potential fraud, waste, and abuse (FWA) include: - ANS-All of the
above
You work for a Sponsor. Last month, while reviewing a Centers for Medicare &
Medicaid Services (CMS) monthly report, you identified multiple individuals not
enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor
who said don't worry about it. This month, you identify the same enrollees on the
report again. What should you do? - ANS-Although you know about the Sponsor's
non-retaliation policy, you are still nervous about reporting—to be safe, you submit
a report through your compliance department's anonymous tip line to avoid
identification
You discover an unattended email address or fax machine in your office receiving
beneficiary appeals requests. You suspect no one is processing the appeals. What
should you do? - ANS-Contact your compliance department (via compliance hotline
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? - ANS-
Follow your pharmacy's procedures
A sales agent, employed by the Sponsor's first-tier, downstream, or related entity
(FDR), submitted an application for processing and requested two things: 1) to back-
date the enrollment date by one month, and 2) to waive all monthly premiums for
the beneficiary. What should you do? - ANS-Process the application properly
(without the requested revisions)—inform your supervisor and the compliance
officer about the sales agent's request
Standards of Conduct are the same for every Medicare Parts C and D sponsor. -
ANS-False
Abuse – 44 questions, AHIP - Modules 1-
5, 105 complete questions and AHIP final
exam-50 verified questions
Under ACA Section 1557, a health plan premium sold through a state exchange
may, based on an individual's age and - ANS-charge higher premiums.
As a result of violations of ACA Section 1557 nondiscrimination rules, - ANS-a
health plan may revoke an agent or broker's appointment with the health plan.
ACA Section 1557 rules for disability concern - ANS-policies and procedures,
physical access, and communication.
Which Medicare programs are covered by ACA Section 1557 under the Biden
Administration's Final Rule (2024)? - ANS-Parts A, C, and D, and Part B.
Which of the following statements best describes Section 1557 of the Affordable
Care Act (ACA)? - ANS-Section 1557 incorporates earlier civil rights protections in
regard to race, color, national origin, disability, age and sex.
Section 1557 of the Affordable Care Act applies to - ANS-all health programs and
activities administered by or receiving federal financial assistance from HHS.
Which of the following would be considered permissible under Section 1557? - ANS-
Broker Mary Jones has recruited a diverse workforce. She encourages her agents to
prospect through community-based marketing and within their community of
influence.
,Which of these actions is most likely to be permitted in dealing with a person with
limited English proficiency? - ANS-Allowing a child to interpret in an emergency.
Which of the following statements best describes the scope of operations subject to
Section 1557 under the Final Rule (2024) of the Biden Administration? - ANS-
Entities principally engaged in health care, which includes health insurers, must
comply with Section 1557 for all programs they offer.
For a health plan, what are the possible consequences of violations of ACA Section
1557? - ANS-Loss of federal business and compensatory damages.
Auxiliary aids and services must be provided to individuals with disabilities, such
as those suffering from vision or hearing impairments, free of charge, and in a
timely manner. Auxiliary aids and services include which of the following:
I. large print materials
II. qualified sign language interpreters
III. braille materials and displays
IV. screen reader software - ANS-I, II, III, and IV
Under ACA Section 1557, a health plan - ANS-cannot deny coverage to LEP
individuals and is required to provide language assistance to them, free of charge.
Under Section 1557, the 2020 Final Rule issued during the Trump Administration
sex was initially defined____________ - ANS-as biologic sex only, meaning whether a
person was determined to be male or female at birth.
Which entity enforces Section 1557 for programs that receive funding from and are
administered by HHS? - ANS-The Office of Civil Rights (OCR) of HHS.
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
Which of the following requires intent to obtain payment and the knowledge the
actions are wrong? - ANS-Fraud
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)
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
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. - ANS-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. - ANS-True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Look for suspicious activity
Conduct yourself in an ethical manner
Ensure accurate and timely data and billing
Ensure you coordinate with other payers
Keep up to date with FWA policies and procedures, standards of conduct, laws,
regulations, and the Centers for Medicare & Medicaid Services (CMS) guidance
Verify all information provided to you - ANS-True
What are some of the penalties for violating fraud, waste, and abuse (FWA) laws? -
ANS-All of the above
These are examples of issues that should be reported to a Compliance Department:
suspected fraud, waste, and abuse (FWA); potential health privacy violation,
unethical behavior, and employee misconduct. - ANS-True
Once a corrective action plan is started, the corrective action plan must be
monitored annually to ensure they are effective. - ANS-False
, 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. - ANS-False
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
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. - ANS-True
Ways to report potential fraud, waste, and abuse (FWA) include: - ANS-All of the
above
You work for a Sponsor. Last month, while reviewing a Centers for Medicare &
Medicaid Services (CMS) monthly report, you identified multiple individuals not
enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor
who said don't worry about it. This month, you identify the same enrollees on the
report again. What should you do? - ANS-Although you know about the Sponsor's
non-retaliation policy, you are still nervous about reporting—to be safe, you submit
a report through your compliance department's anonymous tip line to avoid
identification
You discover an unattended email address or fax machine in your office receiving
beneficiary appeals requests. You suspect no one is processing the appeals. What
should you do? - ANS-Contact your compliance department (via compliance hotline
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? - ANS-
Follow your pharmacy's procedures
A sales agent, employed by the Sponsor's first-tier, downstream, or related entity
(FDR), submitted an application for processing and requested two things: 1) to back-
date the enrollment date by one month, and 2) to waive all monthly premiums for
the beneficiary. What should you do? - ANS-Process the application properly
(without the requested revisions)—inform your supervisor and the compliance
officer about the sales agent's request
Standards of Conduct are the same for every Medicare Parts C and D sponsor. -
ANS-False
