NCICS Healthcare Fraud, Waste & Abuse Prevention 1 — Questions and Answers
Question 1: Which federal law specifically prohibits knowingly submitting false or fraudulent claims to the federal government, including Medicare and Medicaid?
- Anti-Kickback Statute
- False Claims Act (Correct answer)
- Stark Law
- HIPAA Privacy Rule
Correct answer: False Claims Act
The False Claims Act (31 U.S.C. § 3729) is the primary federal law prohibiting submission of false claims to government programs and includes qui tam provisions allowing whistleblowers to file suits on the government's behalf.
Question 2: A provider bills Medicare for a Level 4 office visit when the documentation only supports a Level 2 visit. This is an example of:
- Downcoding
- Unbundling
- Upcoding (Correct answer)
- Churning
Correct answer: Upcoding
Upcoding is the fraudulent practice of billing for a higher-level or more expensive service than was actually documented or provided.
Question 3: Which federal office serves as the primary investigative and enforcement body for Medicare and Medicaid fraud and abuse?
- Centers for Medicare & Medicaid Services (CMS)
- Department of Justice (DOJ)
- HHS Office of Inspector General (OIG) (Correct answer)
- Federal Bureau of Investigation (FBI)
Correct answer: HHS Office of Inspector General (OIG)
The HHS Office of Inspector General (OIG) is the primary federal agency charged with fighting fraud, waste, and abuse in Medicare and Medicaid programs.
Question 4: The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from:
- Billing for services not rendered to patients
- Referring patients for designated health services to entities in which the physician has a financial interest (Correct answer)
- Accepting kickbacks from pharmaceutical companies
- Submitting duplicate claims for the same service
Correct answer: Referring patients for designated health services to entities in which the physician has a financial interest
The Stark Law prohibits physicians from referring patients to receive designated health services payable by Medicare or Medicaid from an entity with which the physician or an immediate family member has a financial relationship.
Question 5: Under the False Claims Act, when the government intervenes in a qui tam lawsuit, what percentage of recovered funds may the whistleblower (relator) receive?
- 5–10%
- 15–25% (Correct answer)
- 30–40%
- 50–60%
Correct answer: 15–25%
When the government intervenes in a qui tam case, the relator is entitled to receive 15–25% of the recovered proceeds; if the government does not intervene, the relator may receive 25–30%.
Question 6: Billing Medicare for a surgical procedure that was never actually performed on a patient is an example of:
- Upcoding
- Churning
- Phantom billing (Correct answer)
- Unbundling
Correct answer: Phantom billing
Phantom billing (billing for services not rendered) involves submitting claims for procedures, services, or supplies that were never actually provided to the patient.
Question 7: Which of the following best defines 'medical necessity' in the context of healthcare fraud prevention?
- All services billed must be documented in the patient's chart regardless of appropriateness
- Services must be clinically appropriate and required for the diagnosis or treatment of illness or injury (Correct answer)
- Providers must use the most advanced treatment available for each condition
- Patients must provide written consent to all procedures before they are performed
Correct answer: Services must be clinically appropriate and required for the diagnosis or treatment of illness or injury
Medical necessity means services must be clinically appropriate, reasonable, and necessary for diagnosis or treatment; billing for services that are not medically necessary is considered fraud.
NCICS Healthcare Fraud, Waste & Abuse Prevention 1
Which federal law specifically prohibits knowingly submitting false or fraudulent claims to the federal government, including Medicare and Medicaid?