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

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:

Accepted Answer

Upcoding

Answer

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?

Accepted Answer

HHS Office of Inspector General (OIG)

Answer

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:

Accepted Answer

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

Answer

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?

Accepted Answer

15–25%

Answer

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%.

NCICS - National Certified Insurance and Coding Specialist Practice Test

NCICS - National Certified Insurance and Coding Specialist Practice Test

NCICS Healthcare Fraud, Waste & Abuse Prevention