AHIP Fraud, Waste, and Abuse (FWA) Prevention

Question 1

How is 'fraud' defined in the context of Medicare and Medicaid?

Accepted Answer

Intentional deception or misrepresentation to obtain an unauthorized benefit or payment

Answer

Fraud is an intentional act of deception or misrepresentation carried out to obtain an unauthorized benefit or payment.

Question 2

Which federal law imposes criminal penalties for knowingly submitting false claims to Medicare or Medicaid?

Accepted Answer

The False Claims Act

Answer

The False Claims Act imposes civil and criminal penalties on anyone who knowingly submits false or fraudulent claims to federal healthcare programs.

Question 3

The Anti-Kickback Statute (AKS) prohibits:

Accepted Answer

Offering or receiving anything of value to induce referrals for Medicare/Medicaid services

Answer

The AKS prohibits offering, paying, soliciting, or receiving remuneration to induce or reward referrals of items or services covered by federal healthcare programs.

Question 4

What is 'upcoding' in healthcare billing?

Accepted Answer

Billing for a more complex or expensive service than was actually provided

Answer

Upcoding involves billing for a higher-level or more expensive service than was actually provided to receive greater reimbursement.

Question 5

Which agency is primarily responsible for investigating Medicare and Medicaid fraud?

Accepted Answer

HHS Office of Inspector General (OIG)

Answer

The HHS Office of Inspector General (OIG) is the primary agency responsible for investigating fraud, waste, and abuse in Medicare and Medicaid.

AHIP - America's Health Insurance Plans Practice Test

AHIP - America's Health Insurance Plans Practice Test

AHIP Fraud, Waste, and Abuse (FWA) Prevention