ACFE Health Care Fraud

Question 1

Which red flag is most associated with a patient-side health care fraud scheme?

Accepted Answer

Doctor shopping to obtain multiple controlled-substance prescriptions

Answer

Doctor shopping, visiting multiple prescribers for the same controlled drugs, is a classic patient-driven scheme, often tied to drug diversion.

Question 2

A provider bills separately for lab tests that should have been billed together as a single panel at a lower rate. Which health care fraud scheme is this?

Accepted Answer

Unbundling

Answer

Unbundling is billing the individual components of a procedure or panel separately to get higher total reimbursement than the bundled code would pay.

Question 3

A physician bills for a complex office visit (CPT 99215) when only a brief visit was performed. This is an example of:

Accepted Answer

Upcoding

Answer

Upcoding is billing a higher-paying code than the service actually delivered.

Question 4

Which U.S. federal statute is most commonly used to prosecute kickbacks paid for referrals of patients covered by federal health care programs?

Accepted Answer

Anti-Kickback Statute

Answer

The Anti-Kickback Statute criminalizes knowingly and willfully offering or receiving remuneration to induce referrals of items or services payable by federal health care programs.

Question 5

A clinic bills Medicare for services to patients who never visited the clinic, using stolen patient identifiers. This scheme is best described as:

Accepted Answer

Phantom billing

Answer

Phantom billing is billing for services, supplies or patients that do not exist or were never provided.

(ACFE) Association of Certified Fraud Examiners Practice Test

(ACFE) Association of Certified Fraud Examiners Practice Test

ACFE Health Care Fraud