Medicare Specialist Fraud, Waste & Abuse Prevention Flashcards
7 cards from real CMS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Medicare Specialist Fraud, Waste & Abuse Prevention flashcards as text
Which federal law is the primary statute used to prosecute Medicare fraud involving false claims submitted to the government?
Answer: The False Claims Act
The False Claims Act (FCA) is the primary federal law used to prosecute entities that knowingly submit false or fraudulent claims to government programs like Medicare.
What is the definition of 'waste' in the context of Medicare fraud, waste, and abuse?
Answer: Overutilization of services due to ignorance or indifference, resulting in unnecessary costs
Waste refers to overutilization of services or other practices that result in unnecessary costs to Medicare, typically due to carelessness or ignorance rather than intent to defraud.
Under the Anti-Kickback Statute (AKS), which of the following activities is prohibited?
Answer: Providing remuneration to induce referrals for Medicare-covered services
The Anti-Kickback Statute prohibits offering, paying, soliciting, or receiving anything of value to induce or reward referrals of items or services covered by Medicare.
Which CMS program is primarily responsible for detecting and preventing Medicare fraud at the claims processing level?
Answer: Recovery Audit Contractor (RAC) program
The Recovery Audit Contractor (RAC) program identifies and corrects improper Medicare payments through post-payment audits of claims submitted by providers.
What is 'upcoding' in the context of Medicare billing fraud?
Answer: Billing for a more expensive service than was actually provided
Upcoding occurs when a provider bills Medicare using a higher-level code than the service actually rendered, resulting in a higher reimbursement than justified.
A Medicare beneficiary reports that they received an Explanation of Benefits (EOB) for services they never received. Which organization should be contacted to report this suspected fraud?
Answer: The HHS Office of Inspector General (OIG)
The HHS Office of Inspector General (OIG) is the primary federal agency responsible for investigating Medicare fraud, and beneficiaries can report suspected fraud to the OIG Hotline.
Which of the following best describes 'abuse' in the Medicare fraud, waste, and abuse framework?
Answer: Practices that are inconsistent with sound fiscal, business, or medical practices that result in unnecessary costs
Abuse involves practices inconsistent with sound fiscal, business, or medical standards that result in unnecessary costs to Medicare, but without the intent required to constitute fraud.