AHIP Comprehensive Study Guide Exam
Questions and Answers Verified Solutions
Latest Update 2026/2027
Answer:
Fraud
• Which of the following is NOT potentially a penalty for violation of a
law or regulation prohibiting Fraud, Waste, and Abuse (FWA)?
Answer:
Deportation
• A person comes to 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 possible forgery. What is your next step?
Answer:
Call the prescriber to verify the quantity
• 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 verify, through a
certain process, that the data is accurate. Your immediate supervisor tells you to ignore the
Sponsor's 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 a certain procedure. You review the same type of
procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any
other provider that you reviewed. What should you do?
Answer:
Questions and Answers Verified Solutions
Latest Update 2026/2027
Answer:
Fraud
• Which of the following is NOT potentially a penalty for violation of a
law or regulation prohibiting Fraud, Waste, and Abuse (FWA)?
Answer:
Deportation
• A person comes to 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 possible forgery. What is your next step?
Answer:
Call the prescriber to verify the quantity
• 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 verify, through a
certain process, that the data is accurate. Your immediate supervisor tells you to ignore the
Sponsor's 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 a certain procedure. You review the same type of
procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any
other provider that you reviewed. What should you do?
Answer:
