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
How is 'fraud' defined in the context of Medicare and Medicaid?
Answer: Intentional deception or misrepresentation to obtain an unauthorized benefit or payment
Fraud is an intentional act of deception or misrepresentation carried out to obtain an unauthorized benefit or payment.
Which federal law imposes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?
Answer: The False Claims Act
The False Claims Act imposes civil and criminal penalties on anyone who knowingly submits false or fraudulent claims to federal healthcare programs.
The Anti-Kickback Statute (AKS) prohibits:
Answer: Offering or receiving anything of value to induce referrals for Medicare/Medicaid services
The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce or reward referrals of items or services covered by federal healthcare programs.
What is 'upcoding' in healthcare billing?
Answer: Billing for a more complex or expensive service than was actually provided
Upcoding involves billing for a higher-level or more expensive service than was actually provided to receive greater reimbursement.
Which agency is primarily responsible for investigating Medicare and Medicaid fraud?
Answer: HHS Office of Inspector General (OIG)
The HHS Office of Inspector General (OIG) is the primary agency responsible for investigating fraud, waste, and abuse in Medicare and Medicaid.
What must Medicare Advantage and Part D plan sponsors do to comply with CMS FWA requirements?
Answer: Implement a comprehensive compliance program including FWA training for employees and first-tier/downstream entities
CMS requires MA and Part D sponsors to maintain a compliance program that includes mandatory FWA training for employees, agents, and contracted entities.