Fraud, Waste, and Abuse (FWA) Prevention Flashcards
6 cards from real AHIP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Fraud, Waste, and Abuse (FWA) Prevention flashcards as text
What is 'waste' in the context of Medicare FWA?
Answer: Overutilization or misuse of resources without intent to defraud
Waste refers to overutilization, misuse, or inefficient use of resources that results in unnecessary program costs, without intentional deception.
A Medicare beneficiary who knowingly lets someone else use their Medicare card commits:
Answer: Fraud
Allowing another person to use your Medicare benefits is Medicare fraud because it involves deliberate misrepresentation to obtain benefits.
What is the OIG Exclusion List?
Answer: A list of individuals and entities excluded from participating in federal healthcare programs due to misconduct
The OIG Exclusion List identifies individuals and entities barred from participating in Medicare, Medicaid, and other federal healthcare programs.
Under HIPAA, individually identifiable health information (PHI) may NOT be disclosed without patient authorization EXCEPT:
Answer: For treatment, payment, or healthcare operations
HIPAA permits disclosure of PHI without authorization for treatment, payment, and healthcare operations (TPO).
Which of the following is an example of 'abuse' rather than 'fraud'?
Answer: Routinely scheduling more follow-up visits than medically necessary without intent to defraud
Abuse involves practices inconsistent with sound medical, business, or fiscal practices that increase program costs, but without deliberate deceptive intent.
What is the purpose of a Medicare Compliance Program for health plans?
Answer: To prevent, detect, and correct non-compliance with CMS requirements and FWA
A compliance program is designed to prevent, detect, and correct violations of CMS requirements and instances of fraud, waste, and abuse.