2025 AHIP - Fraud, Waste, and Abuse Exam with suitable question and answers

2025 AHIP - Fraud, Waste, and Abuse Exam with suitable question and answers 1. Which of the following requires intent to obtain payment and the knowledge the actions are wrong?: Fraud 2. 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 use a process to verify the data is accurate. Your immediate supervisor tells you to ignore the Sponsor's process and to adjust or add risk diagnosis codes for certain individuals. What should you do?: Report the incident to the compliance department (via compliance hotline or other mechanism) 3. Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting fraud, waste, and abuse (FWA)?: Deportation 4. You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do?: Follow your pharmacy's procedures. 5. A person drops 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?: Call the prescriber to verify the quantity 6. You are in charge of paying claims submitted by providers. You notice a cer- tain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large patient group. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do?: Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism)