NCICS Healthcare Fraud, Waste & Abuse Prevention

Question 1

Which federal law specifically prohibits knowingly submitting false or fraudulent claims to the federal government, including Medicare and Medicaid?

Accepted Answer

False Claims Act

Answer

Anti-Kickback Statute

Answer

Stark Law

Answer

HIPAA Privacy Rule

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:

Accepted Answer

Upcoding

Answer

Downcoding

Answer

Unbundling

Answer

Churning

Question 3

Which federal office serves as the primary investigative and enforcement body for Medicare and Medicaid fraud and abuse?

Accepted Answer

HHS Office of Inspector General (OIG)

Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

Department of Justice (DOJ)

Answer

Federal Bureau of Investigation (FBI)

Question 4

The Stark Law (Physician Self-Referral Law) primarily prohibits physicians from:

Accepted Answer

Referring patients for designated health services to entities in which the physician has a financial interest

Answer

Billing for services not rendered to patients

Answer

Accepting kickbacks from pharmaceutical companies

Answer

Submitting duplicate claims for the same service

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?

Accepted Answer

15–25%

Answer

5–10%

Answer

30–40%

Answer

50–60%

Question 6

Billing Medicare for a surgical procedure that was never actually performed on a patient is an example of:

Accepted Answer

Phantom billing

Answer

Upcoding

Answer

Churning

Answer

Unbundling

Question 7

Which of the following best defines 'medical necessity' in the context of healthcare fraud prevention?

Accepted Answer

Services must be clinically appropriate and required for the diagnosis or treatment of illness or injury

Answer

All services billed must be documented in the patient's chart regardless of appropriateness

Answer

Providers must use the most advanced treatment available for each condition

Answer

Patients must provide written consent to all procedures before they are performed