AHIP Fraud, Waste, and Abuse (FWA) Prevention

Question 1

How is 'fraud' defined in the context of Medicare and Medicaid?

Accepted Answer

Intentional deception or misrepresentation to obtain an unauthorized benefit or payment

Answer

Accidental billing errors that are quickly corrected

Answer

Overutilization of services without documentation

Answer

Administrative inefficiencies that increase program costs

Question 2

Which federal law imposes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?

Accepted Answer

The False Claims Act

Answer

HIPAA

Answer

The Anti-Kickback Statute

Answer

The Stark Law

Question 3

The Anti-Kickback Statute (AKS) prohibits:

Accepted Answer

Offering or receiving anything of value to induce referrals for Medicare/Medicaid services

Answer

Billing for services not rendered

Answer

Upcoding medical procedures

Answer

Sharing patient data without consent

Question 4

What is 'upcoding' in healthcare billing?

Accepted Answer

Billing for a more complex or expensive service than was actually provided

Answer

Using outdated billing codes

Answer

Unbundling procedure codes for higher reimbursement

Answer

Failing to submit claims on time

Question 5

Which agency is primarily responsible for investigating Medicare and Medicaid fraud?

Accepted Answer

HHS Office of Inspector General (OIG)

Answer

FBI

Answer

CMS directly

Answer

DEA

Question 6

What must Medicare Advantage and Part D plan sponsors do to comply with CMS FWA requirements?

Accepted Answer

Implement a comprehensive compliance program including FWA training for employees and first-tier/downstream entities

Answer

Submit annual fraud audits to state insurance departments only

Answer

Investigate fraud only upon member complaints

Answer

Report FWA solely to law enforcement without CMS notification