AHIP Discrimination, Fraud, Waste & Abuse 2026 |
Questions & Answers | Latest Update Exam Prep
1. Discuss the implications of accepting bribes or kickbacks in the context of
ACA Section 1557.
Bribes and kickbacks are legal if they are below a certain amount.
Bribes and kickbacks are acceptable if disclosed to the patient.
Accepting bribes or kickbacks is considered fraud and violates
compliance requirements under ACA Section 1557.
Only the person receiving the kickback is liable under ACA Section
1557.
2. A corrective action plan must include
What will be corrected
Steps taken to ensure compliance
All of the mentioned
When it will be corrected
Who is responsible for correcting the deviation
3. What is the correct answer regarding whether the Standards of Conduct are
the same for every Medicare Parts C and D sponsor?
Only for large sponsors
False
Depends on the state
True
,4. A nurse is assessing a Korean-American patient who can not speak English
very well. The patient's family member would like to interpret for them. Which
of the following actions is the best answer?
Hospital policies restrict the participation of patients and their family.
If you want, you can get an interpreter for yourself.
Hospital is able to provide an interpreter for the patient.
Sounds alright, glad they want to help.
5. Under the ACA, can health plans set the premium rate based on a patient's
health status where patients with more complex medical issues are required
to pay a higher premium than patients with less complex medical issues?
Yes, as long as the patient discloses the information when enrolling in
a plan on the health care exchange.
No, health plans are prohibited from participating in the ACA risk
adjustment model.
Yes, as long as the more complex medical conditions are
documented.
No, health plans can not charge different premiums based on health
status.
6. If you are responsible for overseeing compliance in your office and you
discover that beneficiary appeals are not being processed due to an
unattended email address, what steps would you take to rectify the situation?
Delete the email address to prevent further issues.
Notify the compliance department and implement a monitoring
system for appeals.
Wait for someone else to report the issue.
, Assign the task to a random employee.
7. You are in charge of payment of claims submitted from providers. You notice
a certain diagnostic provider, 'Doe Diagnostics,' has 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 do you do?
Consult with your immediate supervisor or Compliance Department
for next steps
Pay the claims
Reject the claims
Call Doe Diagnostics and request additional information for the claims
8. In a hospital setting, if a patient with limited English proficiency is unable to
communicate effectively and a child is present, what should the healthcare
provider do to ensure compliance with ACA Section 1557?
Always use the child to interpret regardless of the situation.
Use the child to interpret only if it is an emergency situation.
Only use professional interpreters, even in emergencies.
Refuse to provide any interpretation services.
9. Which of the following would be considered permissible under Section 1557
and the 2020 Final Rule?
Broker Charles Lee has recruited a diverse workforce. Broker Lee
requires agents to work only in areas populated by those of their
ethnic backgrounds.
, Broker Mary Jones has recruited a diverse workforce. She
encourages her agents to prospect through community-based
marketing and within their community of influence.
Blackheart Agency determines it will require all female members to
pay an additional $20 copay for any wellness visit.
John Smith refuses to accept an application from an individual of a
different race.
10. If a new health insurance plan is developed by a company that primarily
operates in a non-health care sector, what would be the compliance
requirement under Section 1557?
Only the health care providers associated with the plan must comply
with Section 1557.
The company is exempt from Section 1557 as it does not primarily
engage in health care.
The company can choose whether to comply with Section 1557.
The company must comply with Section 1557 for the health
insurance plan it offers.
11. If you encounter a similar situation where a sales agent requests unethical
changes to an application, what steps should you take to ensure compliance
with ACA Section 1557?
Consult with the sales agent for alternative solutions
Process the application with the requested changes to satisfy the
sales agent
Document the request, process the application as per regulations,
and report the incident to your supervisor and compliance officer
Ignore the request if it seems unethical
Questions & Answers | Latest Update Exam Prep
1. Discuss the implications of accepting bribes or kickbacks in the context of
ACA Section 1557.
Bribes and kickbacks are legal if they are below a certain amount.
Bribes and kickbacks are acceptable if disclosed to the patient.
Accepting bribes or kickbacks is considered fraud and violates
compliance requirements under ACA Section 1557.
Only the person receiving the kickback is liable under ACA Section
1557.
2. A corrective action plan must include
What will be corrected
Steps taken to ensure compliance
All of the mentioned
When it will be corrected
Who is responsible for correcting the deviation
3. What is the correct answer regarding whether the Standards of Conduct are
the same for every Medicare Parts C and D sponsor?
Only for large sponsors
False
Depends on the state
True
,4. A nurse is assessing a Korean-American patient who can not speak English
very well. The patient's family member would like to interpret for them. Which
of the following actions is the best answer?
Hospital policies restrict the participation of patients and their family.
If you want, you can get an interpreter for yourself.
Hospital is able to provide an interpreter for the patient.
Sounds alright, glad they want to help.
5. Under the ACA, can health plans set the premium rate based on a patient's
health status where patients with more complex medical issues are required
to pay a higher premium than patients with less complex medical issues?
Yes, as long as the patient discloses the information when enrolling in
a plan on the health care exchange.
No, health plans are prohibited from participating in the ACA risk
adjustment model.
Yes, as long as the more complex medical conditions are
documented.
No, health plans can not charge different premiums based on health
status.
6. If you are responsible for overseeing compliance in your office and you
discover that beneficiary appeals are not being processed due to an
unattended email address, what steps would you take to rectify the situation?
Delete the email address to prevent further issues.
Notify the compliance department and implement a monitoring
system for appeals.
Wait for someone else to report the issue.
, Assign the task to a random employee.
7. You are in charge of payment of claims submitted from providers. You notice
a certain diagnostic provider, 'Doe Diagnostics,' has 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 do you do?
Consult with your immediate supervisor or Compliance Department
for next steps
Pay the claims
Reject the claims
Call Doe Diagnostics and request additional information for the claims
8. In a hospital setting, if a patient with limited English proficiency is unable to
communicate effectively and a child is present, what should the healthcare
provider do to ensure compliance with ACA Section 1557?
Always use the child to interpret regardless of the situation.
Use the child to interpret only if it is an emergency situation.
Only use professional interpreters, even in emergencies.
Refuse to provide any interpretation services.
9. Which of the following would be considered permissible under Section 1557
and the 2020 Final Rule?
Broker Charles Lee has recruited a diverse workforce. Broker Lee
requires agents to work only in areas populated by those of their
ethnic backgrounds.
, Broker Mary Jones has recruited a diverse workforce. She
encourages her agents to prospect through community-based
marketing and within their community of influence.
Blackheart Agency determines it will require all female members to
pay an additional $20 copay for any wellness visit.
John Smith refuses to accept an application from an individual of a
different race.
10. If a new health insurance plan is developed by a company that primarily
operates in a non-health care sector, what would be the compliance
requirement under Section 1557?
Only the health care providers associated with the plan must comply
with Section 1557.
The company is exempt from Section 1557 as it does not primarily
engage in health care.
The company can choose whether to comply with Section 1557.
The company must comply with Section 1557 for the health
insurance plan it offers.
11. If you encounter a similar situation where a sales agent requests unethical
changes to an application, what steps should you take to ensure compliance
with ACA Section 1557?
Consult with the sales agent for alternative solutions
Process the application with the requested changes to satisfy the
sales agent
Document the request, process the application as per regulations,
and report the incident to your supervisor and compliance officer
Ignore the request if it seems unethical
