2025 AHIP - Fraud, Waste, and Abuse
Which of the following requires intent to obtain payment and the knowledge the actions are
wrong? - ANS Fraud
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? - ANS Report the incident to the
compliance department (via compliance hotline or other mechanism)
Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting
fraud, waste, and abuse (FWA)? - ANS Deportation
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 pharmacy's
procedures.
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? - ANS Call the prescriber to verify the quantity
You are in charge of paying claims submitted by providers. You notice a certain 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? - ANS Consult with your immediate supervisor for next steps or
contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or
other mechanism)
Bribes or kickbacks of any kind for services that are paid under a Federal health care program
(which includes Medicare) constitute fraud by the person making as well as the person receiving
them. - ANS True
Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the
Health Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the
Anti-Kickback Statute, and the Criminal Health Care Fraud Statute. - ANS True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
Which of the following requires intent to obtain payment and the knowledge the actions are
wrong? - ANS Fraud
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? - ANS Report the incident to the
compliance department (via compliance hotline or other mechanism)
Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting
fraud, waste, and abuse (FWA)? - ANS Deportation
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 pharmacy's
procedures.
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? - ANS Call the prescriber to verify the quantity
You are in charge of paying claims submitted by providers. You notice a certain 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? - ANS Consult with your immediate supervisor for next steps or
contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or
other mechanism)
Bribes or kickbacks of any kind for services that are paid under a Federal health care program
(which includes Medicare) constitute fraud by the person making as well as the person receiving
them. - ANS True
Some of the laws governing Medicare Part C and D fraud, waste, and abuse (FWA) include the
Health Insurance Portability and Accountability Act (HIPAA), the Civil False Claims Act, the
Anti-Kickback Statute, and the Criminal Health Care Fraud Statute. - ANS True
You can help prevent fraud, waste, and abuse (FWA) by doing all the following:
