Exam (elaborations)
2024/2025 Medicare+ Fraud, Waste, and Abuse
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2024/2025 Medicare+ Fraud, Waste, and Abuse
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2024 Medicare+ Fraud, Waste, andAbuse
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? - ANSReport the incident to the
compliance department (via compliance hotline 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? - ANSFollow your pharmacy's
procedures.
Which of the following requires intent to obtain payment and the knowledge the actions are
wrong? - ANSFraud
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? - ANSCall the perscriber 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? - ANSConsult with your immediate supervisor for next steps or
contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], 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)? - ANSDeportation
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. - ANSTrue
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. - ANSFalse
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