AHIP Fraud Waste and Abuse Questions With Verified Answers

AHIP Fraud Waste and Abuse Questions With Verified Answers Which of the following requires intent to obtain payment and the knowledge that the actions are wrong? - ANSWER Fraud Which of the following is NOT potentially a penalty for violation of a law or regulation prohibiting Fraud, Waste, and Abuse (FWA)? - ANSWER Deportation A person comes to 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 possible forgery. What is your next step? - 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 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 a certain procedure. You review the same type of procedure for other diagnostic providers and realize that Doe Diagnostics' claims far exceed any other provider that you reviewed. What should you do? - ANSWER Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations 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? - ANSWER Follow your pharmacy's procedures Compliance is the responsibility of the Compliance Officer, Compliance Committee, and Upper Management only. - ANSWER False Ways to report a compliance issue include: - 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 begins addressing non-compliance or Fraud, Waste, and Abuse (FWA) committed by a Sponsor's employee or First-Tier, Downstream, or Related Entity's (FDR's) employee, ongoing monitoring of the corrective actions is not necessary. - ANSWER False Medicare Parts C and D plan Sponsors are not required to have a compliance program. - ANSWER False At a minimum, an effective compliance program includes four core requirements. - ANSWER False Standards of Conduct are the same for every Medicare Parts C and D Sponsor. - ANSWER False Correcting non-compliance ______________. - ANSWER Protects enrollees, avoids recurrence of the same noncompliance, and promotes efficienc What are some of the consequences for non-compliance, fraudulent, or unethical be