AHIP Fraud, Waste, and Abuse (FWA) Prevention 1 — Questions and Answers
Question 1: How is 'fraud' defined in the context of Medicare and Medicaid?
- Accidental billing errors that are quickly corrected
- Intentional deception or misrepresentation to obtain an unauthorized benefit or payment (Correct answer)
- Overutilization of services without documentation
- Administrative inefficiencies that increase program costs
Correct 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.
Question 2: Which federal law imposes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?
- HIPAA
- The Anti-Kickback Statute
- The False Claims Act (Correct answer)
- The Stark Law
Correct 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.
Question 3: The Anti-Kickback Statute (AKS) prohibits:
- Billing for services not rendered
- Offering or receiving anything of value to induce referrals for Medicare/Medicaid services (Correct answer)
- Upcoding medical procedures
- Sharing patient data without consent
Correct 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.
Question 4: What is 'upcoding' in healthcare billing?
- Using outdated billing codes
- Billing for a more complex or expensive service than was actually provided (Correct answer)
- Unbundling procedure codes for higher reimbursement
- Failing to submit claims on time
Correct 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.
Question 5: Which agency is primarily responsible for investigating Medicare and Medicaid fraud?
- FBI
- HHS Office of Inspector General (OIG) (Correct answer)
- CMS directly
- DEA
Correct 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.
Question 6: What must Medicare Advantage and Part D plan sponsors do to comply with CMS FWA requirements?
- Submit annual fraud audits to state insurance departments only
- Implement a comprehensive compliance program including FWA training for employees and first-tier/downstream entities (Correct answer)
- Investigate fraud only upon member complaints
- Report FWA solely to law enforcement without CMS notification
Correct 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.
AHIP Fraud, Waste, and Abuse (FWA) Prevention 1
How is 'fraud' defined in the context of Medicare and Medicaid?