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, avo