1
AHIP FINAL EXAM TEST
[2025 LATEST UPDATED VERSION]
You ,are ,performing ,a ,regular ,inventory ,of ,the ,controlled ,substances ,in ,the
,pharmacy.,You ,discover ,a ,minor ,inventory ,discrepancy. ,What ,should ,you
,do?correct answersFollow ,your ,pharmacy's ,procedures
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?correct
,answersReport ,the ,incident ,to ,the ,compliance ,department ,(via ,compliance
,hotline ,or ,other ,mechanism)
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 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 ,Doe ,Diagnostics' claims ,far ,exceed ,any
,other ,provider ,you ,reviewed. ,What ,should ,you ,do?correct ,answersConsult
,with ,your ,immediate ,supervisor ,for ,next ,steps ,or ,contact ,the compliance
,department ,(via ,compliance ,hotline, ,Special ,Investigations ,Unit ,[SIU], ,orother
,mechanism)
,2
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?correct ,answersCall ,the prescriber ,to ,verify ,the ,quantity
,3
Waste ,includes ,any ,misuse ,of ,resources, ,such ,as ,the ,overuse ,of ,services ,or
,other,practices ,that ,directly ,or ,indirectly ,result ,in ,unnecessary ,costs ,to ,the
,Medicare Program.correct ,answersTrue
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.correct ,answersTrue
These ,are ,examples ,of ,issues ,that ,should ,be ,reported ,to ,a ,Compliance
,Department: suspected ,fraud, ,waste, ,and ,abuse ,(FWA); ,potential ,health
,privacy ,violation, ,unethical,behavior, ,and ,employee ,misconduct.correct
,answersTrue
Abuse ,involves ,payment ,for ,items ,or ,services ,when ,there ,is ,no ,legal
,entitlement ,to ,that,payment ,and ,the ,provider ,has ,not ,knowingly ,or
,intentionally ,misrepresented ,facts ,to obtain ,payment.correct ,answersTrue
, 4
Ways ,to ,report ,potential ,fraud, ,waste, ,and ,abuse ,(FWA)
,include:,a. ,Mail ,drops
b. ,Special ,Investigative ,Units
,(SIUs),c. ,Tekephone ,hotlinesd. ,All
,of ,the ,above
e. ,In-person ,reporting ,to ,the ,compliance ,department/supervisorcorrect
,answersAll ,of ,the,above
Once ,a ,corrective ,action ,plan ,is ,started, ,the ,corrective ,action ,plan ,must ,be
,monitored,annually ,to ,ensure ,they ,are ,effective.correct ,answersFalse
What ,are ,some ,of ,the ,penalties ,for ,violating ,fraud, ,waste, ,and ,abuse
,(FWA) ,laws?,a.Civil ,Monetary ,Penalties
b.Imprisonment
c.All ,of ,the
,above
d.Exclusion ,from ,participation ,in ,all ,Federal ,health ,care ,programscorrect
,answersAll ,of,the ,above
Any ,person ,who ,knowingly ,submits ,false ,claims ,to ,the ,Government ,is
,liable ,for ,five,times ,the ,Government's ,damages ,caused ,by ,the ,violator ,plus
,a ,penalty.correct answersFalse
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 ,False ,Claims ,Act ,the ,Anti-Kickback ,Statute, ,and ,the ,Health
,Care ,Fraud ,Statute.correct answersFalse
AHIP FINAL EXAM TEST
[2025 LATEST UPDATED VERSION]
You ,are ,performing ,a ,regular ,inventory ,of ,the ,controlled ,substances ,in ,the
,pharmacy.,You ,discover ,a ,minor ,inventory ,discrepancy. ,What ,should ,you
,do?correct answersFollow ,your ,pharmacy's ,procedures
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?correct
,answersReport ,the ,incident ,to ,the ,compliance ,department ,(via ,compliance
,hotline ,or ,other ,mechanism)
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 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 ,Doe ,Diagnostics' claims ,far ,exceed ,any
,other ,provider ,you ,reviewed. ,What ,should ,you ,do?correct ,answersConsult
,with ,your ,immediate ,supervisor ,for ,next ,steps ,or ,contact ,the compliance
,department ,(via ,compliance ,hotline, ,Special ,Investigations ,Unit ,[SIU], ,orother
,mechanism)
,2
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?correct ,answersCall ,the prescriber ,to ,verify ,the ,quantity
,3
Waste ,includes ,any ,misuse ,of ,resources, ,such ,as ,the ,overuse ,of ,services ,or
,other,practices ,that ,directly ,or ,indirectly ,result ,in ,unnecessary ,costs ,to ,the
,Medicare Program.correct ,answersTrue
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.correct ,answersTrue
These ,are ,examples ,of ,issues ,that ,should ,be ,reported ,to ,a ,Compliance
,Department: suspected ,fraud, ,waste, ,and ,abuse ,(FWA); ,potential ,health
,privacy ,violation, ,unethical,behavior, ,and ,employee ,misconduct.correct
,answersTrue
Abuse ,involves ,payment ,for ,items ,or ,services ,when ,there ,is ,no ,legal
,entitlement ,to ,that,payment ,and ,the ,provider ,has ,not ,knowingly ,or
,intentionally ,misrepresented ,facts ,to obtain ,payment.correct ,answersTrue
, 4
Ways ,to ,report ,potential ,fraud, ,waste, ,and ,abuse ,(FWA)
,include:,a. ,Mail ,drops
b. ,Special ,Investigative ,Units
,(SIUs),c. ,Tekephone ,hotlinesd. ,All
,of ,the ,above
e. ,In-person ,reporting ,to ,the ,compliance ,department/supervisorcorrect
,answersAll ,of ,the,above
Once ,a ,corrective ,action ,plan ,is ,started, ,the ,corrective ,action ,plan ,must ,be
,monitored,annually ,to ,ensure ,they ,are ,effective.correct ,answersFalse
What ,are ,some ,of ,the ,penalties ,for ,violating ,fraud, ,waste, ,and ,abuse
,(FWA) ,laws?,a.Civil ,Monetary ,Penalties
b.Imprisonment
c.All ,of ,the
,above
d.Exclusion ,from ,participation ,in ,all ,Federal ,health ,care ,programscorrect
,answersAll ,of,the ,above
Any ,person ,who ,knowingly ,submits ,false ,claims ,to ,the ,Government ,is
,liable ,for ,five,times ,the ,Government's ,damages ,caused ,by ,the ,violator ,plus
,a ,penalty.correct answersFalse
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 ,False ,Claims ,Act ,the ,Anti-Kickback ,Statute, ,and ,the ,Health
,Care ,Fraud ,Statute.correct answersFalse
