WCC EXAM 2 STUDY GUIDE
QUESTIONS & ACCURATE ANSWERS
PASSED 100%
Know major reasons for why the healthcare system is unique in terms of WCC. -
CORRECT ANSWER offenders are trained and trusted
victims don't have knowledge
highly self-regualted
Be familiar with following terms: fraud, abuse, Medicare, Medicaid - CORRECT
ANSWER medicare-elderly
medicaid-poor
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds
What is the most pervasive form of fraud in the healthcare system? - CORRECT
ANSWER medicare/medicaid fraud
what factors make Medicare/Medicaid fraud more likely? - CORRECT ANSWER
government has to pay out within 30 days
How do physicians engage in fraud and abuse? - CORRECT ANSWER phantom
treatment, substitute providers, upcoding, falsifying records, unnecessary services,
unbundling, overcharging patients, ping pong and kickback schemes, ganging, co-pay
waivers, medical snowballing
Know about medical malpractice and the term iatrogenic events - CORRECT ANSWER
the distinction from fraud to malpractice is harm; events that cause more harm than
good
He kept performing angiograms on people that did not need it - CORRECT ANSWER
He kept performing angiograms on people that did not need it
What are the social/cultural contexts that make physician fraud more likely? -
CORRECT ANSWER Victim vulnerability- uncertainty is the primary reason for medical
consultations
Patient/public demand for treatment- disease fear, physician trust (not insurance), faith
in system
Economic structure of system- "fee for service" rather than wellness outcomes
, What did the Al-Jazeera documentary on pharmaceutical fraud suggest was a major
form of unethical or criminal behavior undertaken by large drug-making companies? -
CORRECT ANSWER prescribing medication not approved for certain diseases
What are the consequences of medical malpractice, especially in terms of unnecessary
services? - CORRECT ANSWER difficult to get good estimates because data primarily
relies on civil trials
Injuries and death
Depriving those truly in need
Wasted time of patients
Why do crimes by doctors get such little attention from criminologists, media, and
general public? - CORRECT ANSWER because of the respect, power, and trust that
the profession engenders
What is the most pervasive form of fraud committed by doctors? - CORRECT
ANSWER Medicare and Medicaid fraud and abuse
What are some (not all) of the methods by which doctors might engage in fraud? -
CORRECT ANSWER 1) phantom treatment
-providers bill medicaid, medicare, or other insurance companies for services they never
provided
2) substitute providers
-the medical services were performed by an employee who was not authorized to
perform them
3) upcoding (upgrading)
-providers bill for services that were more expensive than the services provided
4) provision of unnecessary services
5) misrepresenting services
-providers describe services rendered differently in an an attempt to gain payment
6) falsifying records
- providers change medical forms to be reimbursed by insurance provider
7) overcharging patients
8) unbundling
-provider bills separately for tests/services that were supposed to be charged as one
procedure
9) pingponging
-patients unnecessarily referred to other doctors and are "bounced around"
10) ganging
- providers bill for multiple family members when they only treated one
11) kickbacks
12) co-pay waivers
13) medical snowballing
QUESTIONS & ACCURATE ANSWERS
PASSED 100%
Know major reasons for why the healthcare system is unique in terms of WCC. -
CORRECT ANSWER offenders are trained and trusted
victims don't have knowledge
highly self-regualted
Be familiar with following terms: fraud, abuse, Medicare, Medicaid - CORRECT
ANSWER medicare-elderly
medicaid-poor
fraud: intentionally criminal behaviors by physicians
abuse: unintentional misuse of program funds
What is the most pervasive form of fraud in the healthcare system? - CORRECT
ANSWER medicare/medicaid fraud
what factors make Medicare/Medicaid fraud more likely? - CORRECT ANSWER
government has to pay out within 30 days
How do physicians engage in fraud and abuse? - CORRECT ANSWER phantom
treatment, substitute providers, upcoding, falsifying records, unnecessary services,
unbundling, overcharging patients, ping pong and kickback schemes, ganging, co-pay
waivers, medical snowballing
Know about medical malpractice and the term iatrogenic events - CORRECT ANSWER
the distinction from fraud to malpractice is harm; events that cause more harm than
good
He kept performing angiograms on people that did not need it - CORRECT ANSWER
He kept performing angiograms on people that did not need it
What are the social/cultural contexts that make physician fraud more likely? -
CORRECT ANSWER Victim vulnerability- uncertainty is the primary reason for medical
consultations
Patient/public demand for treatment- disease fear, physician trust (not insurance), faith
in system
Economic structure of system- "fee for service" rather than wellness outcomes
, What did the Al-Jazeera documentary on pharmaceutical fraud suggest was a major
form of unethical or criminal behavior undertaken by large drug-making companies? -
CORRECT ANSWER prescribing medication not approved for certain diseases
What are the consequences of medical malpractice, especially in terms of unnecessary
services? - CORRECT ANSWER difficult to get good estimates because data primarily
relies on civil trials
Injuries and death
Depriving those truly in need
Wasted time of patients
Why do crimes by doctors get such little attention from criminologists, media, and
general public? - CORRECT ANSWER because of the respect, power, and trust that
the profession engenders
What is the most pervasive form of fraud committed by doctors? - CORRECT
ANSWER Medicare and Medicaid fraud and abuse
What are some (not all) of the methods by which doctors might engage in fraud? -
CORRECT ANSWER 1) phantom treatment
-providers bill medicaid, medicare, or other insurance companies for services they never
provided
2) substitute providers
-the medical services were performed by an employee who was not authorized to
perform them
3) upcoding (upgrading)
-providers bill for services that were more expensive than the services provided
4) provision of unnecessary services
5) misrepresenting services
-providers describe services rendered differently in an an attempt to gain payment
6) falsifying records
- providers change medical forms to be reimbursed by insurance provider
7) overcharging patients
8) unbundling
-provider bills separately for tests/services that were supposed to be charged as one
procedure
9) pingponging
-patients unnecessarily referred to other doctors and are "bounced around"
10) ganging
- providers bill for multiple family members when they only treated one
11) kickbacks
12) co-pay waivers
13) medical snowballing
