AHIP Fraud, Waste, and Abuse (FWA) Prevention 3

Question 1

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

Accepted Answer

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

Answer

Any specialist without a written order

Answer

Out-of-network providers without prior authorization

Answer

Pharmacies not on the preferred network

Question 2

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

Accepted Answer

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

Answer

Handle the matter internally without escalating

Answer

Advise the beneficiary to file a private lawsuit

Answer

Ignore it unless directly instructed by CMS

Question 3

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

Accepted Answer

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

Answer

A beneficiary filling a 90-day supply at mail order

Answer

Using a preferred pharmacy for cost savings

Answer

Requesting a formulary exception for a non-covered drug

Question 4

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

Accepted Answer

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

Answer

A beneficiary changing their plan during AEP

Answer

A provider using an expired NPI number

Answer

A plan enrolling beneficiaries without their knowledge

Question 5

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

Accepted Answer

Annually as part of certification requirements

Answer

Once at initial certification only

Answer

Only after a compliance violation

Answer

Every three years

Question 6

What is 'phantom billing' in healthcare fraud?

Accepted Answer

Billing for services that were never actually rendered

Answer

Billing for a service at a higher level than provided

Answer

Billing a secondary insurer after the primary has paid

Answer

Sending duplicate claims to two different insurers