CMS Medicare Specialist Fraud, Waste & Abuse Prevention 3

Question 1

What is the primary purpose of the OIG's List of Excluded Individuals and Entities (LEIE)?

Accepted Answer

To list providers who are prohibited from participating in federal healthcare programs

Answer

To identify Medicare beneficiaries who have committed fraud

Answer

To track Medicare claims with high error rates

Answer

To identify Medicare Advantage plans with compliance violations

Question 2

Which of the following scenarios best illustrates a 'kickback' violation under the Anti-Kickback Statute?

Accepted Answer

A durable medical equipment company offering lavish gifts to physicians to prescribe their products to Medicare patients

Answer

A hospital providing free continuing education to its own employed physicians

Answer

A physician waiving a copay for a Medicare beneficiary experiencing financial hardship

Answer

A pharmacy offering a loyalty discount program to all cash-paying customers

Question 3

In Medicare compliance programs, what is the role of a 'compliance officer'?

Accepted Answer

To oversee the organization's compliance program and ensure adherence to Medicare regulations

Answer

To audit Medicare claims for coding accuracy only

Answer

To represent the organization in Medicare fraud investigations

Answer

To negotiate Medicare reimbursement rates with CMS

Question 4

What is 'phantom billing' in the context of Medicare fraud?

Accepted Answer

Billing Medicare for services or equipment never provided to patients

Answer

Billing for services at an inflated rate

Answer

Billing multiple payers for the same service

Answer

Billing using another provider's NPI number

Question 5

When must an organization report and return an identified Medicare overpayment under the 60-day rule?

Accepted Answer

Within 60 days of identifying the overpayment

Answer

Within 30 days of identification

Answer

Within 90 days of the fiscal year end

Answer

Within 180 days of the claim date

Question 6

A Medicare-enrolled provider is found guilty of healthcare fraud. In addition to criminal penalties, which administrative sanction can CMS/OIG impose?

Accepted Answer

Exclusion from participation in Medicare and other federal healthcare programs

Answer

Mandatory referral to state licensing board only

Answer

Suspension of the provider's DEA registration

Answer

Revocation of the provider's hospital privileges

Question 7

Which element distinguishes fraud from abuse in Medicare program integrity?

Accepted Answer

The knowing and willful intent to deceive the Medicare program

Answer

The dollar amount of the improper payment

Answer

Whether the service was medically necessary

Answer

Whether the provider has a prior violation history