Fraud, Waste, and Abuse (FWA) Prevention Flashcards

The Stark Law (Physician Self-Referral Law) prohibits physicians from referring patients to:

Answer: An entity providing designated health services in which the physician has a financial relationship, unless an exception applies

The Stark Law prohibits physicians from making referrals for certain designated health services to entities with which they (or an immediate family member) have a financial relationship, unless an exception applies.

If an agent suspects Medicare fraud, they are required to:

Answer: Report it to the plan's compliance department or to 1-800-MEDICARE

Agents and plan employees are required to report suspected fraud to the plan's compliance department; beneficiaries and the public can report to 1-800-MEDICARE.

Which of the following is an indicator of potential prescription drug fraud in Part D?

Answer: A beneficiary receiving the same controlled substance from multiple prescribers (doctor shopping)

Obtaining the same controlled substance from multiple prescribers — 'doctor shopping' — is a key indicator of prescription drug fraud or abuse.

What is 'identity theft' in the context of Medicare fraud?

Answer: Using someone else's Medicare number to obtain healthcare services or bill for services

Medicare identity theft involves using another person's Medicare number or beneficiary information to fraudulently obtain services or reimbursement.

CMS requires Medicare Advantage and Part D agents to complete FWA training:

Answer: Annually as part of certification requirements

CMS requires agents selling MA and Part D plans to complete annual FWA training as part of their certification requirements.

What is 'phantom billing' in healthcare fraud?

Answer: Billing for services that were never actually rendered

Phantom billing refers to submitting claims for medical services, supplies, or equipment that were never actually provided to the patient.