CMS Medicare Specialist Fraud, Waste & Abuse Prevention 1 — Questions and Answers
Question 1: Which federal law is the primary statute used to prosecute Medicare fraud involving false claims submitted to the government?
- The Anti-Kickback Statute
- The False Claims Act (Correct answer)
- The Stark Law
- The Civil Monetary Penalties Law
Correct 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.
Question 2: What is the definition of 'waste' in the context of Medicare fraud, waste, and abuse?
- Intentional deception to obtain unauthorized benefits
- Overutilization of services due to ignorance or indifference, resulting in unnecessary costs (Correct answer)
- Offering remuneration to induce Medicare referrals
- Billing for services not rendered to patients
Correct 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.
Question 3: Under the Anti-Kickback Statute (AKS), which of the following activities is prohibited?
- Billing Medicare for medically necessary services
- Offering discounts to cash-paying patients
- Providing remuneration to induce referrals for Medicare-covered services (Correct answer)
- Submitting claims within the allowed time limit
Correct 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.
Question 4: Which CMS program is primarily responsible for detecting and preventing Medicare fraud at the claims processing level?
- Medicare Advantage Organization (MAO)
- Comprehensive Error Rate Testing (CERT)
- Recovery Audit Contractor (RAC) program (Correct answer)
- Medicare Administrative Contractor (MAC) program
Correct 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.
Question 5: What is 'upcoding' in the context of Medicare billing fraud?
- Using a code for a less expensive service than was actually performed
- Billing for a more expensive service than was actually provided (Correct answer)
- Submitting duplicate claims for the same service
- Using an outdated CPT code on a claim
Correct 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.
Question 6: 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?
- The Social Security Administration (SSA)
- The HHS Office of Inspector General (OIG) (Correct answer)
- The Centers for Disease Control (CDC)
- The Department of Labor (DOL)
Correct 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.
Question 7: Which of the following best describes 'abuse' in the Medicare fraud, waste, and abuse framework?
- Knowingly billing for services never rendered
- Practices that are inconsistent with sound fiscal, business, or medical practices that result in unnecessary costs (Correct answer)
- Intentionally misrepresenting diagnoses to justify services
- Offering cash incentives to Medicare beneficiaries for referrals
Correct 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.
CMS Medicare Specialist Fraud, Waste & Abuse Prevention 1
Which federal law is the primary statute used to prosecute Medicare fraud involving false claims submitted to the government?