Fraud, Waste, Abuse - 2, Fraud Waste and Abuse, Preventing Fraud, Abuse & Waste,
Fraud, Abuse, and Waste, Fraud Waste and Abuse 2025 AHIP, fraud, waste, and abuse
prevention Study Set
An individual presents to your pharmacy to drop off a prescription for a beneficiary who
is a "regular" customer with your pharmacy. The prescription is for a controlled
substance, with a quantity of 160. The beneficiary in question usually receives a quantity
of 60, not 160. You process the prescription and have some concerns that this might be
a forged prescription. What would you do? - 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 responsible for the payment of claims submitted by providers. You identify that
a diagnostic provider, "Doe Diagnostics" has requested a large payment for a large
number of members. Many of these claims are for a specific procedure. You review the
same type of procedure for other diagnostic providers and notice that the claims for
Doe Diagnostics are far and above any other provider you reviewed. What do you do? -
ANSWER>>Refer to immediate supervisor for next steps or the compliance department
via compliance hotline, Special Investigations Unit (SIU), or other mechanism
You are doing a routine count of the pharmacy's controlled substances inventory. You
find a small inventory discrepancy. What do you do? - ANSWER>>Follow your
pharmacy's processes
Special Investigation Units (SIUs) report potential FWA in the following ways: -
ANSWER>>SIUs
,When a corrective action plan is initiated, the corrective actions must be tracked yearly
to be certain that the actions are successful. - ANSWER>>True
Anything that can be considered a bribe or kickback, in return for services that are paid
under a Federal health care program includes Medicare. Fraud by the person making as
well as the person receiving them. - ANSWER>>True
The following are examples of issues that should be reported to a Compliance
Department: suspected FWA; health privacy violation, and unethical behavior/employee
misconduct. - ANSWER>>True
Any person who knowingly presents false claims to the Government is liable for five
times the Government's damages caused by the violator plus a penalty. -
ANSWER>>False
Abuse involves payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly and/or intentionally misrepresented facts
to obtain payment. - ANSWER>>True
You can help prevent Fraud, Waste, and Abuse by doing all of the following:
• Look for suspicious activity;
• Conduct yourself in an ethical manner;
• Ensure accurate and timely data/billing;
• Ensure you coordinate with other payers;
• Keep up to date with FWA policies and procedures, standards of conduct, laws,
regulations, and the Centers for Medicare & Medicaid Services guidance; and
• Verify all information provided to you. - ANSWER>>True
Any misuse of a resource such as overuse of services, or other practices that directly or
indirectly result in unnecessary costs to the Medicare Program constitutes waste. -
ANSWER>>True
, What are some of the consequences of violation under FWA?
Select the best answer. - ANSWER>>All of the above
Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse (FWA)
include the Health Insurance Portability and Accountability Act (HIPAA); the False
Claims Act; the Anti-Kickback Statute; the List of Excluded Individuals and Entities
(LEIE); and the Health Care Fraud Statute. - ANSWER>>True
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and
Upper Management only. - ANSWER>>False
Ways to report a compliance issue include:
Select the correct answer. - ANSWER>>All of the above
What is the policy of non-retaliation? - ANSWER>>Protects employees who, in good
faith, report suspected non-compliance
These are examples of issues that can be reported to a Compliance Department:
suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and
unethical behavior/employee misconduct. - ANSWER>>True
Once a corrective action plan is addressing non-compliance or FWA committed by a
Sponsor's employee or employee of the FDR, no ongoing monitoring of the corrective
actions is required. - ANSWER>>False
Medicare Parts C and D plan Sponsors are exempt from having to have a compliance
program. - ANSWER>>False
Fraud, Abuse, and Waste, Fraud Waste and Abuse 2025 AHIP, fraud, waste, and abuse
prevention Study Set
An individual presents to your pharmacy to drop off a prescription for a beneficiary who
is a "regular" customer with your pharmacy. The prescription is for a controlled
substance, with a quantity of 160. The beneficiary in question usually receives a quantity
of 60, not 160. You process the prescription and have some concerns that this might be
a forged prescription. What would you do? - 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 responsible for the payment of claims submitted by providers. You identify that
a diagnostic provider, "Doe Diagnostics" has requested a large payment for a large
number of members. Many of these claims are for a specific procedure. You review the
same type of procedure for other diagnostic providers and notice that the claims for
Doe Diagnostics are far and above any other provider you reviewed. What do you do? -
ANSWER>>Refer to immediate supervisor for next steps or the compliance department
via compliance hotline, Special Investigations Unit (SIU), or other mechanism
You are doing a routine count of the pharmacy's controlled substances inventory. You
find a small inventory discrepancy. What do you do? - ANSWER>>Follow your
pharmacy's processes
Special Investigation Units (SIUs) report potential FWA in the following ways: -
ANSWER>>SIUs
,When a corrective action plan is initiated, the corrective actions must be tracked yearly
to be certain that the actions are successful. - ANSWER>>True
Anything that can be considered a bribe or kickback, in return for services that are paid
under a Federal health care program includes Medicare. Fraud by the person making as
well as the person receiving them. - ANSWER>>True
The following are examples of issues that should be reported to a Compliance
Department: suspected FWA; health privacy violation, and unethical behavior/employee
misconduct. - ANSWER>>True
Any person who knowingly presents false claims to the Government is liable for five
times the Government's damages caused by the violator plus a penalty. -
ANSWER>>False
Abuse involves payment for items or services when there is no legal entitlement to that
payment and the provider has not knowingly and/or intentionally misrepresented facts
to obtain payment. - ANSWER>>True
You can help prevent Fraud, Waste, and Abuse by doing all of the following:
• Look for suspicious activity;
• Conduct yourself in an ethical manner;
• Ensure accurate and timely data/billing;
• Ensure you coordinate with other payers;
• Keep up to date with FWA policies and procedures, standards of conduct, laws,
regulations, and the Centers for Medicare & Medicaid Services guidance; and
• Verify all information provided to you. - ANSWER>>True
Any misuse of a resource such as overuse of services, or other practices that directly or
indirectly result in unnecessary costs to the Medicare Program constitutes waste. -
ANSWER>>True
, What are some of the consequences of violation under FWA?
Select the best answer. - ANSWER>>All of the above
Some of the laws governing Medicare Parts C and D Fraud, Waste, and Abuse (FWA)
include the Health Insurance Portability and Accountability Act (HIPAA); the False
Claims Act; the Anti-Kickback Statute; the List of Excluded Individuals and Entities
(LEIE); and the Health Care Fraud Statute. - ANSWER>>True
Compliance is the responsibility of the Compliance Officer, Compliance Committee, and
Upper Management only. - ANSWER>>False
Ways to report a compliance issue include:
Select the correct answer. - ANSWER>>All of the above
What is the policy of non-retaliation? - ANSWER>>Protects employees who, in good
faith, report suspected non-compliance
These are examples of issues that can be reported to a Compliance Department:
suspected Fraud, Waste, and Abuse (FWA); potential health privacy violation, and
unethical behavior/employee misconduct. - ANSWER>>True
Once a corrective action plan is addressing non-compliance or FWA committed by a
Sponsor's employee or employee of the FDR, no ongoing monitoring of the corrective
actions is required. - ANSWER>>False
Medicare Parts C and D plan Sponsors are exempt from having to have a compliance
program. - ANSWER>>False
