WCC Exam 2 Study Guide with
Complete Solutions
offenders are trained and trusted
victims don't have knowledge
highly self-regualted - ANS-Know major reasons for why the healthcare system is
unique in terms of WCC.
medicare-elderly
medicaid-poor
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds - ANS-Be familiar with following terms:
fraud, abuse, Medicare, Medicaid
medicare/medicaid fraud - ANS-What is the most pervasive form of fraud in the
healthcare system?
government has to pay out within 30 days - ANS-what factors make Medicare/Medicaid
fraud more likely?
phantom treatment, substitute providers, upcoding, falsifying records, unnecessary
services, unbundling, overcharging patients, ping pong and kickback schemes, ganging,
co-pay waivers, medical snowballing - ANS-How do physicians engage in fraud and
abuse?
the distinction from fraud to malpractice is harm; events that cause more harm than
good - ANS-Know about medical malpractice and the term iatrogenic events
He kept performing angiograms on people that did not need it - ANS-He kept performing
angiograms on people that did not need it
Victim vulnerability- uncertainty is the primary reason for medical consultations
Patient/public demand for treatment- disease fear, physician trust (not insurance), faith
in system
Economic structure of system- "fee for service" rather than wellness outcomes - ANS-
What are the social/cultural contexts that make physician fraud more likely?
prescribing medication not approved for certain diseases - ANS-What did the Al-
Jazeera documentary on pharmaceutical fraud suggest was a major form of unethical or
criminal behavior undertaken by large drug-making companies?
, difficult to get good estimates because data primarily relies on civil trials
Injuries and death
Depriving those truly in need
Wasted time of patients - ANS-What are the consequences of medical malpractice,
especially in terms of unnecessary services?
because of the respect, power, and trust that the profession engenders - ANS-Why do
crimes by doctors get such little attention from criminologists, media, and general
public?
Medicare and Medicaid fraud and abuse - ANS-What is the most pervasive form of
fraud committed by doctors?
1) phantom treatment
-providers bill medicaid, medicare, or other insurance companies for services they never
provided
2) substitute providers
-the medical services were performed by an employee who was not authorized to
perform them
3) upcoding (upgrading)
-providers bill for services that were more expensive than the services provided
4) provision of unnecessary services
5) misrepresenting services
-providers describe services rendered differently in an an attempt to gain payment
6) falsifying records
- providers change medical forms to be reimbursed by insurance provider
7) overcharging patients
8) unbundling
-provider bills separately for tests/services that were supposed to be charged as one
procedure
9) pingponging
-patients unnecessarily referred to other doctors and are "bounced around"
10) ganging
- providers bill for multiple family members when they only treated one
11) kickbacks
12) co-pay waivers
13) med - ANS-What are some (not all) of the methods by which doctors might engage
in fraud?
physicians - ANS-Of several different medical professionals identified in Payne's 1995
study of Providers Accused of Fraud and Abuse, which type of provider had the
HIGHEST number of accusations made about them?
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds - ANS-Difference between fraud and
abuse
Complete Solutions
offenders are trained and trusted
victims don't have knowledge
highly self-regualted - ANS-Know major reasons for why the healthcare system is
unique in terms of WCC.
medicare-elderly
medicaid-poor
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds - ANS-Be familiar with following terms:
fraud, abuse, Medicare, Medicaid
medicare/medicaid fraud - ANS-What is the most pervasive form of fraud in the
healthcare system?
government has to pay out within 30 days - ANS-what factors make Medicare/Medicaid
fraud more likely?
phantom treatment, substitute providers, upcoding, falsifying records, unnecessary
services, unbundling, overcharging patients, ping pong and kickback schemes, ganging,
co-pay waivers, medical snowballing - ANS-How do physicians engage in fraud and
abuse?
the distinction from fraud to malpractice is harm; events that cause more harm than
good - ANS-Know about medical malpractice and the term iatrogenic events
He kept performing angiograms on people that did not need it - ANS-He kept performing
angiograms on people that did not need it
Victim vulnerability- uncertainty is the primary reason for medical consultations
Patient/public demand for treatment- disease fear, physician trust (not insurance), faith
in system
Economic structure of system- "fee for service" rather than wellness outcomes - ANS-
What are the social/cultural contexts that make physician fraud more likely?
prescribing medication not approved for certain diseases - ANS-What did the Al-
Jazeera documentary on pharmaceutical fraud suggest was a major form of unethical or
criminal behavior undertaken by large drug-making companies?
, difficult to get good estimates because data primarily relies on civil trials
Injuries and death
Depriving those truly in need
Wasted time of patients - ANS-What are the consequences of medical malpractice,
especially in terms of unnecessary services?
because of the respect, power, and trust that the profession engenders - ANS-Why do
crimes by doctors get such little attention from criminologists, media, and general
public?
Medicare and Medicaid fraud and abuse - ANS-What is the most pervasive form of
fraud committed by doctors?
1) phantom treatment
-providers bill medicaid, medicare, or other insurance companies for services they never
provided
2) substitute providers
-the medical services were performed by an employee who was not authorized to
perform them
3) upcoding (upgrading)
-providers bill for services that were more expensive than the services provided
4) provision of unnecessary services
5) misrepresenting services
-providers describe services rendered differently in an an attempt to gain payment
6) falsifying records
- providers change medical forms to be reimbursed by insurance provider
7) overcharging patients
8) unbundling
-provider bills separately for tests/services that were supposed to be charged as one
procedure
9) pingponging
-patients unnecessarily referred to other doctors and are "bounced around"
10) ganging
- providers bill for multiple family members when they only treated one
11) kickbacks
12) co-pay waivers
13) med - ANS-What are some (not all) of the methods by which doctors might engage
in fraud?
physicians - ANS-Of several different medical professionals identified in Payne's 1995
study of Providers Accused of Fraud and Abuse, which type of provider had the
HIGHEST number of accusations made about them?
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds - ANS-Difference between fraud and
abuse
