AHIP TRAINING Medicare Fraud, Waste, and Abuse Training Practice Exam With Explanations Of Answers.

Medicare plan means - correct answer A MA plan, MA-PD plan or PDP Subcontractor means - correct answer **An individual or entity that provides services on behalf of a Medicare plan sponsor. This includes individuals and organizations with DIRECT relationship with the plan sponsor or individuals or organizations with INDIRECT relationship, such as an agent who has a contract with an agency or filed marketing organization that contract with a Medicare plan. FWA Training: A compliance program component - correct answer **ALL Medicare plans are required to have robust programs to assure compliance by plan employees an subcontractors with all applicable laws, regulations and program guidance. **One required component of a compliance program is a FWA program to identify and address issues of compliance with FWA. **It is important to remember that ALL Medicare plan sponsor employees and subcontractors are responsible for complying with all relevant Medicare requirements, even if lack of compliance may not be viewed as FWA, FWA: Why participate in the training - correct answer **Fraud, waste and abuse impacts everyone who receives or relies on healthcare in the US. **The purpose of this training is to help you detect, correct and prevent FWA and your help is needed. You are part of the solution! **As a subcontractor to or an employee of a Medicare plan, you are required to participate in FWA training. FWA: Combating: A federal priority - correct answer **Important priority for the Federal Government. **CMS, the Federal agency responsible for administering these programs, takes its role in leading anti-fraud efforts very seriously and has issued strict requirements for those involved in providing MA and Medicare Part D coverage. **The office of Inspector General, a sister agency to CMS within the US Department of Health and Human Services , is also actively involved in anti-fraud efforts. Steps by Medicare plans to Combat FWA - correct answer --The establishment and operation of special investigation units (SIU) or other existing departments that perform an internal investigation function --The analysis of claims data --Collaboration with law enforcement agencies --Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud, waste and abuse. CMS Anti-FWA requirements for Medicare plans - correct answer --Actively seek to prevent fraud, waste and abuse --Detect and investigate suspected FWA --Implement corrective action when instances of FWA are uncovered --Have a system in place 24 hrs per day for employees and subcontractors to voluntarily, and confidentially report suspected FWA or misconduct related to the MA and Part D programs CMS FWA training requirements for a Sponsor's Employees - correct answer **CMS requires Medicare plan sponsors to provide training in FWA to their employees involved in Medicare plan work. **This training must occur within 90 days of hire and annually thereafter. CMS FWA training requirements: Agents, Brokers and other Subcontractors - correct answer **The FWA training must be received not only by Medicare plan sponsor employees but also by subcontractors and their employees who are under contract to provide health or administrative services. The EXCEPTIONS are limited to: ***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS) ***Healthcare providers who are enrolled in Medicare Part A/B CMS FWA training requirements: Agents, Brokers and other Subcontractors Those required to take the training including, but not limited to: - correct answer --Insurance agents, brokers as well as employees of agencies and field marketing organizations that are performing services for Medicare plans --Employees of other vendors and subcontractors (such as claim processing firms) --Pharmacies and employees of Pharmacy benefit Managers FWA Definitions and examples - correct answer FRAUD is an intentional act of deception, misrepresentation, or concealment in order to gain something of value. Fraud often involves criminal behavior. ABUSE results in unwarranted payments from or costs to a Federal healthcare consumer, provider, or other person obtains money to which they are not entitled, but there is not the intent to deceive that is necessary for fraud to have occurred. Abuse often involves actions which are inconsistent with accepted medical and/or business practices. WASTE occurs when poor or inefficient practices result in unnecessary healthcare expenditures to a Government program. Who Commits Medicare FWA? - correct answer 1. Medicare beneficiaries 2. Physicians and other healthcare providers 3. Pharmacies, pharmacists, and pharmaceutical manufacturers and wholesalers 4. Health plan employees 5. Insurance agents and brokers 6. parties who neither provide not receive healthcare (professional criminals, including members of organized crime) 7. Combinations of the above working together in collusion. Defining Fraud: A Closer look - correct answer **According to the health care fraud criminal statute Healthcare fraud is: knowingly and willfully executing, or attempting to execute, a scheme or artifice, to defraud any healthcare benefit program or to obtain, by means of false or fraudulent pretenses, representations, or promises, any of the money or property owned by, or under the custody or control of, any health benefit program" **Healthcare fraud can result in civil and criminal penalties that include fines, monetary damages, and even imprisonment. **Additionally, there is a penalty of up to 20 years in prison or life in prison if the violation resulted in a person's death. FWA Related to Agents and Brokers - correct answer --An agent offers Medicare beneficiaries cash or other impermissible incentives to enroll in the Rx plan he represents. --An agent offers beneficiaries money for names, address and phone numbers of friends and acquaintances who are Medicare beneficiaries. --An agent forges a beneficiary's signature on an enrollment form. --An agent intentionally misrepresents a plan's costs or benefits for the purpose of attaining enrollment, or convincing someone to enroll. --An individual solicits MA enrollments and gather "initial premiums". She is not really an agent and disappears with the money. FWA Involving Medicare Plan Sponsors - correct answer --The amt. MA plan enrollees must pay for certain services is greater than what the sponsor's literature implies. --An MA plan realizes it had been overpaid by the Medicare program but fails to report it to the CMS --An MA plan fails to disenroll an enrollee (and continues receiving payment for the enrollee) even though it knows the enrollee has permanently moved from the plan service area. Summarizing the Importance of FWA Detection, Correction, and Prevention - correct answer **Most providers, supplies, pharmacists, and sale representatives who work with Medicare are honest and seek to do the right thing. But there are a few individuals and organizations that knowingly commit fraud, while others engage in practices that result in waste or abuse. **CMS and Medicare plan sponsors are committed to providing quality healthcare services to Medicare beneficiaries while reducing the costs of fraud, waste and abuse. These costs take the form of not only lost dollars, but also of a negative impact on the quality of life of Medicare beneficiaries. Fraud, waste, and abuse can inflict real physical and emotional harm. **This training has been designed to provide you with tools you need to participate in the ongoing efforts against fraud, waste and abuse. AUDIT - correct answer **A methodical examination and review of data or processes with the purpose of verifying the data's accuracy or whether established processes are in place or are properly followed. Civil monetary penalties CMP's - correct answer Penalties that may be imposed for a variety of conduct including Medicare FWA. Different amts. of penalties and assessments may be authorized based on the type of violation and can range as high as $50,000 per violation. Example: Presenting a claim that a person knows or should know is for a service that was NOT provided as claimed or is false and fraudulent