CMS Medicare Specialist Fraud, Waste & Abuse Prevention

Question 1

Which federal law is the primary statute used to prosecute Medicare fraud involving false claims submitted to the government?

Accepted Answer

The False Claims Act

Answer

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?

Accepted Answer

Overutilization of services due to ignorance or indifference, resulting in unnecessary costs

Answer

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?

Accepted Answer

Providing remuneration to induce referrals for Medicare-covered services

Answer

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?

Accepted Answer

Recovery Audit Contractor (RAC) program

Answer

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?

Accepted Answer

Billing for a more expensive service than was actually provided

Answer

Upcoding occurs when a provider bills Medicare using a higher-level code than the service actually rendered, resulting in a higher reimbursement than justified.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Fraud, Waste & Abuse Prevention