AHIP FRAUD WASTE & ABUSE QUESTIONS
AND ACCURATE ANSWERS.
Which of the following requires intent to obtain payment and the knowledge that the actions are
wrong? ANS -Fraud
Which of the following is not potentially a penalty for violation of the law or regulation prohibiting
fraud, waste and abuse (fwa)? ANS -Deportation
A person comes into 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 the possible
forgery. What is your next step? ANS -Call the prescriber to verify the quantity
Your job is to submit 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 sponsors process and to adjust/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)
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 certain procedure. You review the same type of procedure for other diagnostic providers
and realize that doe diagnostics' claim far exceed any other provider that you reviewed. What should
you do? ANS -Consult with your immediate supervisor for the next steps or contact the compliance
department (via compliance hotline, special investigation unit (siu), 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 pharmacys procedures
AND ACCURATE ANSWERS.
Which of the following requires intent to obtain payment and the knowledge that the actions are
wrong? ANS -Fraud
Which of the following is not potentially a penalty for violation of the law or regulation prohibiting
fraud, waste and abuse (fwa)? ANS -Deportation
A person comes into 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 the possible
forgery. What is your next step? ANS -Call the prescriber to verify the quantity
Your job is to submit 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 sponsors process and to adjust/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)
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 certain procedure. You review the same type of procedure for other diagnostic providers
and realize that doe diagnostics' claim far exceed any other provider that you reviewed. What should
you do? ANS -Consult with your immediate supervisor for the next steps or contact the compliance
department (via compliance hotline, special investigation unit (siu), 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 pharmacys procedures
