AHIP Fraud, Waste, and Abuse (FWA) Prevention 2 — Questions and Answers
Question 1: What is 'waste' in the context of Medicare FWA?
- Intentional overcharging for services
- Overutilization or misuse of resources without intent to defraud (Correct answer)
- Billing for services never rendered
- Criminal diversion of Medicare funds
Correct 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.
Question 2: A Medicare beneficiary who knowingly lets someone else use their Medicare card commits:
- Waste
- Abuse
- Fraud (Correct answer)
- A billing error
Correct answer: Fraud
Allowing another person to use your Medicare benefits is Medicare fraud because it involves deliberate misrepresentation to obtain benefits.
Question 3: What is the OIG Exclusion List?
- A list of fraudulent beneficiaries barred from Medicare
- A list of individuals and entities excluded from participating in federal healthcare programs due to misconduct (Correct answer)
- A CMS list of non-contracted pharmacies
- A state-level registry of abusive billing providers
Correct 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.
Question 4: Under HIPAA, individually identifiable health information (PHI) may NOT be disclosed without patient authorization EXCEPT:
- When requested by a marketing company
- For treatment, payment, or healthcare operations (Correct answer)
- To employers for productivity monitoring
- To family members without the patient's knowledge
Correct answer: For treatment, payment, or healthcare operations
HIPAA permits disclosure of PHI without authorization for treatment, payment, and healthcare operations (TPO).
Question 5: Which of the following is an example of 'abuse' rather than 'fraud'?
- Billing for services not provided
- Falsifying a diagnosis to justify payment
- Routinely scheduling more follow-up visits than medically necessary without intent to defraud (Correct answer)
- Forging patient signatures on medical records
Correct 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.
Question 6: What is the purpose of a Medicare Compliance Program for health plans?
- To replace state insurance department oversight
- To prevent, detect, and correct non-compliance with CMS requirements and FWA (Correct answer)
- To manage plan premiums and deductibles
- To handle member grievances exclusively
Correct 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.
AHIP Fraud, Waste, and Abuse (FWA) Prevention 2
What is 'waste' in the context of Medicare FWA?