Fraud, Waste, Abuse – 1 (2022/2023)
Graded A+
ACA Section 1557 differs from earlier legislation in providing broader protection against
discrimination based on
a. disability.
b. national origin.
c. age.
d. sex. ✔✔d
Section 1557 of the Affordable Care Act applies to
a. all health programs and activities administered by or receiving federal financial assistance
from HHS.
b. Medicare Advantage plans only.
c. all health programs and activities, public and private.
d. health plans sold through the ACA Marketplaces only. ✔✔a
Which Medicare programs are covered by ACA Section 1557?
a. Part C (Medicare Advantage) only.
b. Parts A, C, and D, but not B.
c. Part D (prescription drug coverage) only.
d. Parts A and B (Original Medicare) only. ✔✔b
Under ACA Section 1557, prohibited actions involve
a. marketing only.
b. claims only.
c. eligibility, claims, and marketing.
d. eligibility only. ✔✔c
Under ACA Section 1557, a person
a. can be discriminated against if she is unable to speak English.
b. can be discriminated against if she is an immigrant (legal or illegal).
Fraud Waste and Abuse (FWA) Training
Questions and Answers 100% Pass
How to recognize FWA in the Medicare Program ✔✔Knowledge of the law including the Civil
False claims Act, Health Care Fraud Statute, and Criminal Fraud, Anti-Kickback Statute, Stark
Statute, Exclusion from all Federal healthcare programs, and the Health Insurance Portability and
Accountability Act.
Civil False Claims Act ✔✔Makes a person liable to pay damages to the government if
- He or she knowingly conspires to commit FWA.
- Carries out other acts to obtain property from the government by misrepresentation.
- Conceals or improperly avoids or decreases an obligation to pay the government.
- Makes or uses a false record or statement supporting a false claim.
- Presents a false claim for payment or approval.
Health Care Fraud statute ✔✔”Whoever knowingly and willfully executes, or attempts to
execute, a scheme or artifice of defraud any healthcare benefit program…shall be fined under this
title or imprisoned not more than 10 years, or both.”
AHIP TRAINING Medicare Fraud, Waste,
and Abuse Training Questions and
Answers with Verified Solutions
Medicare plan means ✔✔A MA plan, MA-PD plan or PDP
Subcontractor means ✔✔An individual or entity that provides services on behalf of a Medicare plan sponsor. This includes individuals and organizations with DIRECT relationship with the plan sponsor or individuals or organizations with INDIRECT relationship, such as an agent who has a contract with an agency or filed marketing organization that contract with a Medicare plan. FWA Training: A compliance program component ✔✔ALL Medicare plans are required to
have robust programs to assure compliance by plan employees an subcontractors with all
applicable laws, regulations and program guidance.
**One required component of a compliance program is a FWA program to identify and address
issues of compliance with FWA.
**It is important to remember that ALL Medicare plan sponsor employees and subcontractors
are responsible for complying with all relevant Medicare requirements, even if lack of
compliance may not be viewed as FWA,
FWA: Why participate in the training ✔✔**Fraud, waste and abuse impacts everyone who
receives or relies on healthcare in the US.
**The purpose of this training is to help you detect, correct and prevent FWA and your help is
needed. You are part of the solution!
As a subcontractor to or an employee of a Medicare plan, you are required to participate in FWA training. FWA: Combating: A federal priority ✔✔Important priority for the Federal Government.
**CMS, the Federal agency responsible for administering these programs, takes its role in
leading anti-fraud efforts very seriously and has issued strict requirements for those involved in
providing MA and Medicare Part D coverage.
**The office of Inspector General, a sister agency to CMS within the US Department of Health
and Human Services , is also actively involved in anti-fraud efforts.
Steps by Medicare plans to Combat FWA ✔✔–The establishment and operation of special
investigation units (SIU) or other existing departments that perform an internal investigation
function
–The analysis of claims data
–Collaboration with law enforcement agencies
–Adherence to rules set forth by CMS regarding efforts to identify and prevent fraud, waste and
abuse.
CMS Anti-FWA requirements for Medicare plans ✔✔–Actively seek to prevent fraud, waste
and abuse
–Detect and investigate suspected FWA
–Implement corrective action when instances of FWA are uncovered
–Have a system in place 24 hrs per day for employees and subcontractors to voluntarily, and
confidentially report suspected FWA or misconduct related to the MA and Part D programs
CMS FWA training requirements for a Sponsor’s Employees ✔✔**CMS requires Medicare plan
sponsors to provide training in FWA to their employees involved in Medicare plan work.
*This training must occur within 90 days of hire and annually thereafter. CMS FWA training requirements: Agents, Brokers and other Subcontractors ✔✔*The FWA
training must be received not only by Medicare plan sponsor employees but also by
subcontractors and their employees who are under contract to provide health or administrative
services. The EXCEPTIONS are limited to:
***accredited suppliers of DME, prosthetics, orthotics, and supplies (DMEPOS)
***Healthcare providers who are enrolled in Medicare Part A/B
Fraud, Waste, Abuse – 2 Latest 2023
Graded A+
Ways to report potential Fraud, Waste, and Abuse (FWA) include:
a. Telephone hotlines
b. Mail Drops
c. In-person reporting to the compliance department/supervisor
d. Special Investigations Units (SIUs)
e. All of the above ✔✔e
Once a corrective action plan is started, the corrective actions must be monitored annually to
ensure they are effective.
:
True False ✔✔false
Any person who knowingly submits false claims to the Government is liable for five times the
Government’s damages caused by the violator plus a penalty.
AHIP fraud waste & abuse questions and
answers already passed
Which of the following requires intent to obtain payment and the knowledge that the actions are
wrong? ✔✔Fraud
Which of the following is not potentially a penalty for violation of the law or regulation
prohibiting fraud, waste and abuse (fwa)? ✔✔Deportation
A person comes into your pharmacy to drop off a prescription for a beneficiary who is a regular
customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary
normally receives a quantity of 60, not 160. You review the prescription and have concerns
about the possible forgery. What is your next step? ✔✔Call the prescriber to verify the quantity
Your job is to submit risk diagnosis to the centers for Medicare & medicaid services (cms) for
the purpose of payment. As part of this job you verify, through a certain process, that the data is
accurate. Your immediate supervisor tells you to ignore the sponsors process and to adjust/add
risk diagnosis codes for certain individuals. What should you do? ✔✔Report the incident to the
compliance department (via compliance hotline or other mechanism)
Medicare Fraud, Waste, & Abuse
(2022/2023) (Certified Answers)
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS)
for the purpose of payment. As part of this job, you use a process to verify the data is accurate.
Your immediate supervisor tells you to ignore the Sponsor’s process and to adjust or add risk
diagnosis codes for certain individuals. What should you do?
a.Do what your immediate supervisor asked you to do and adjust or add risk diagnosis codes
b.Report the incident to the compliance department (via compliance hotline or other mechanism)
c.Discuss your concerns with your immediate supervisor
d.Call law enforcement ✔✔Report the incident to the compliance department (via compliance
hotline or other mechanism)
Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting fraud, waste, and abuse (FWA)?
a.Civil Monetary Penalties
b.Exclusion from participation in all Federal health care programs
c.Deportatio ✔✔Deportation
Which of the following requires intent to obtain payment and the knowledge the actions are
wrong?
a.Fraud
b.Waste
c.Abuse ✔✔Fraud
A person drops off a prescription for a beneficiary who is a “regular” customer. The prescription
is for a controlled substance with a quantity of 160. This beneficiary normally receives a quantity
of 60, not 160. You review the prescription and have concerns about possible forgery. What is
your next step?
a.Call law enforcement
b.Call the prescriber to verify the quantity
c.Call the Sponsor’s compliance department
d.Fill the prescription for 160
e.Fill the prescription for 60 ✔✔Call the prescriber to verify the quantity
Combating Medicare Parts C&D Fraud,
Waste & Abuse Questions and Answers
100% Pass
Once a corrective action plan is started, the corrective actions must be monitored annually to
ensure they are effective. ✔✔False
Ways to report potential fraud, waste, and abuse (FWA) include: ✔✔All of the above
Any person who knowingly submits false claims to the government is liable for five times the
government’s damages caused by the violator plus a penalty. ✔✔False
These are examples of issues that should be reported to a compliance department: suspected
fraud, waste, and abuse (FWA); potential health privacy violation; unethical behavior; and
employee misconduct. ✔✔True
Bribes or kickbacks of any kind for services that are paid under a federal health care program
(which includes medicare) constitute fraud by the person making as well as the person receiving
them. ✔✔True
Combating Medicare Parts C&D Fraud,
Waste & Abuse Questions and Answers
100% Pass
Once a corrective action plan is started, the corrective actions must be monitored annually to
ensure they are effective. ✔✔False
Ways to report potential fraud, waste, and abuse (FWA) include: ✔✔All of the above
Any person who knowingly submits false claims to the government is liable for five times the
government’s damages caused by the violator plus a penalty. ✔✔False
These are examples of issues that should be reported to a compliance department: suspected
fraud, waste, and abuse (FWA); potential health privacy violation; unethical behavior; and
employee misconduct. ✔✔True
Bribes or kickbacks of any kind for services that are paid under a federal health care program
(which includes medicare) constitute fraud by the person making as well as the person receiving
them. ✔✔True
Combating Medicare Parts C and D
Fraud, Waste, and Abuse – 2012/2023
Already Passed
Bribes or kickbacks of any kind for services that are paid under a Federal healthcare program
(which includes Medicare) constitute fraud by the person making as well as the person receiving
them. ✔✔True
Once a corrective action plan is started, the corrective actions must be monitored annually to
ensure they are effective. ✔✔False
Any person who knowingly submits false claims to the Government is liable for five times the
Government’s damages caused by the violator plus a penalty. ✔✔False
Waste indicates any misuse of resources such as the overuse of services, or other practices that
directly or indirectly result in unnecessary costs to the Medicare Program. ✔✔True
These are examples of issues that should be reported to a Compliance Department: suspected
fraud, waste, and abuse (FWA); potential health privacy violation; and unethical
behavior/employee misconduct. ✔✔True
AHIP FWA 2023 Questions and Answers
100% Pass
Mrs. Turner is comparing her employer’s retiree insurance to Original Medicare and would like
to know which of the following services Original Medicare will cover if the appropriate criteria
are met? What could you tell her? ✔✔Original Medicare covers ambulance services.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage
plan. What should you tell him? ✔✔Mr. Singh can enroll in a stand-alone prescription drug plan
and continue to be covered for Part A and Part B services through Original Fee-for-Service
Medicare.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being
successfully treated for that condition. However, she and her physicians feel that after her
lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What
should you tell them about Original Medicare’s coverage of care in a skilled nursing facility?
✔✔Medicare will cover Mrs. Shield’s skilled nursing services provided during the first 20 days
of her stay, after which she would have a copay until she has been in the facility for 100 days.
Madeline Martinez was widowed several years ago. Her husband worked for many years and
contributed into the Medicare system. He also left a substantial estate which provides Madeline
with an annual income of approximately $130,000. Madeline, who has only worked part-time for
the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to
you for advice. What should you tell her? ✔✔You should tell Madeline that she will be able to
enroll in Medicare Part A without paying monthly premiums due to her husband’s long work
record and participation in the Medicare system. You should also tell Madeline that she will pay
Part B premiums at more than the standard lowest rate but less than the highest rate due her
substantial income.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis
through massage therapy. She is concerned about whether or not Medicare will cover these items
and services. What should you tell her? ✔✔Medicare does not cover massage therapy, or, in
general, glasses or dentures.
Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social
Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she has been
automatically enrolled in Medicare Part B. She wants to understand what this means. What
should you tell Mrs. Quinn? ✔✔Part B primarily covers physician services. She will be paying a
monthly premium and, with the exception of many preventive and screening tests, generally will
have 20% coinsurance for these services, in addition to an annual deductible.
Mrs. Geisler’s neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can’t
remember what Part D is so she called you to ask what her neighbor was talking about. What
could you tell her? ✔✔Part D covers prescription drugs and she should look at her premiums,
formulary, and cost-sharing among other factors to see if they have changed.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her
Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one
of her claims for services. What advice would you give her? ✔✔Mrs. Duarte should file an
appeal of this initial determination within 120 days of the date she received the MSN in the mail.
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be
hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an
inpatient psychiatric hospital stay that Medicare will cover? ✔✔Medicare will cover a total of
190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park
that might be of assistance? ✔✔She should contact her state Medicaid agency to see if she
qualifies for one of several programs that can help with Medicare costs for which she is
responsible.
Anita Magri will turn age 65 in August 2022. Anita intends to enroll in Original Medicare Part A
and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita’s
older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not
only provides foreign travel emergency benefits but also covers his Medicare Part B deductible.
Anita comes to you for advice. What should you tell her? ✔✔You are sorry to disappoint Anita
but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020.
Anita might instead consider other Medigap plans that offer foreign travel benefits but do not
cover the Part B deductible.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes.
What should you tell her? ✔✔To obtain Part B coverage, she must pay a standard monthly
premium, though it is higher for individuals with higher incomes.
Mr. Alonso receives some help paying for his two generic prescription drugs from his employer’s
retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what
costs he would generally expect to encounter when enrolling into a standard Medicare Part D
prescription drug plan. What should you tell him? ✔✔He generally would pay a monthly
premium, annual deductible, and per-prescription cost-sharing.
AHIP FWA 2023 Questions and Answers
with Verified Solutions
Mrs. Turner is comparing her employer’s retiree insurance to Original Medicare and would like
to know which of the following services Original Medicare will cover if the appropriate criteria
are met? What could you tell her? ✔✔Original Medicare covers ambulance services.
Mr. Singh would like drug coverage but does not want to be enrolled in a Medicare Advantage
plan. What should you tell him? ✔✔Mr. Singh can enroll in a stand-alone prescription drug plan
and continue to be covered for Part A and Part B services through Original Fee-for-Service
Medicare.
Mrs. Shields is covered by Original Medicare. She sustained a hip fracture and is being
successfully treated for that condition. However, she and her physicians feel that after her
lengthy hospital stay she will need a month or two of nursing and rehabilitative care. What
should you tell them about Original Medicare’s coverage of care in a skilled nursing facility?
✔✔Medicare will cover Mrs. Shield’s skilled nursing services provided during the first 20 days
of her stay, after which she would have a copay until she has been in the facility for 100 days.
Madeline Martinez was widowed several years ago. Her husband worked for many years and
contributed into the Medicare system. He also left a substantial estate which provides Madeline
with an annual income of approximately $130,000. Madeline, who has only worked part-time for
the last three years, will soon turn age 65 and hopes to enroll in Original Medicare. She comes to
you for advice. What should you tell her? ✔✔You should tell Madeline that she will be able to
enroll in Medicare Part A without paying monthly premiums due to her husband’s long work
record and participation in the Medicare system. You should also tell Madeline that she will pay
Part B premiums at more than the standard lowest rate but less than the highest rate due her
substantial income.
Mrs. West wears glasses and dentures and has enjoyed considerable pain relief from arthritis
through massage therapy. She is concerned about whether or not Medicare will cover these items
and services. What should you tell her? ✔✔Medicare does not cover massage therapy, or, in
general, glasses or dentures.
Mrs. Quinn recently turned 66 and decided after many years of work to begin receiving Social
Security benefits. Shortly thereafter Mrs. Quinn received a letter informing her that she has been
automatically enrolled in Medicare Part B. She wants to understand what this means. What
should you tell Mrs. Quinn? ✔✔Part B primarily covers physician services. She will be paying a
monthly premium and, with the exception of many preventive and screening tests, generally will
have 20% coinsurance for these services, in addition to an annual deductible.
Mrs. Geisler’s neighbor told her she should look at her Part D options during the annual
Medicare enrollment period because features of Part D might have changed. Mrs. Geisler can’t
remember what Part D is so she called you to ask what her neighbor was talking about. What
could you tell her? ✔✔Part D covers prescription drugs and she should look at her premiums,
formulary, and cost-sharing among other factors to see if they have changed.
Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her
Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one
of her claims for services. What advice would you give her? ✔✔Mrs. Duarte should file an
appeal of this initial determination within 120 days of the date she received the MSN in the mail.
Mr. Rainey is experiencing paranoid delusions and his physician feels that he should be
hospitalized. What should you tell Mr. Rainey (or his representative) about the length of an
inpatient psychiatric hospital stay that Medicare will cover? ✔✔Medicare will cover a total of
190 days of inpatient psychiatric care during Mr. Rainey’s entire lifetime.
Mrs. Park is an elderly retiree. Mrs. Park has a low fixed income. What could you tell Mrs. Park
that might be of assistance? ✔✔She should contact her state Medicaid agency to see if she
qualifies for one of several programs that can help with Medicare costs for which she is
responsible.
Anita Magri will turn age 65 in August 2022. Anita intends to enroll in Original Medicare Part A
and Part B. She would also like to enroll in a Medicare Supplement (Medigap) plan. Anita’s
older neighbor Mel has told her about the Medigap Part F plan in which he is enrolled. It not
only provides foreign travel emergency benefits but also covers his Medicare Part B deductible.
Anita comes to you for advice. What should you tell her? ✔✔You are sorry to disappoint Anita
but a Medigap Part F plan is no longer available to those who turn age 65 after January 1,2020.
Anita might instead consider other Medigap plans that offer foreign travel benefits but do not
cover the Part B deductible.
Ms. Henderson believes that she will qualify for Medicare Coverage when she turns 65, without
paying any premiums, because she has been working for 40 years and paying Medicare taxes.
What should you tell her? ✔✔To obtain Part B coverage, she must pay a standard monthly
premium, though it is higher for individuals with higher incomes.
Mr. Alonso receives some help paying for his two generic prescription drugs from his employer’s
retiree coverage, but he wants to compare it to a Part D prescription drug plan. He asks you what
costs he would generally expect to encounter when enrolling into a standard Medicare Part D
prescription drug plan. What should you tell him? ✔✔He generally would pay a monthly
premium, annual deductible, and per-prescription cost-sharing.
AHIP FWA Questions and Answers with
Certified Solutions
Which of the following requires intent to obtain payment and the knowledge that the actions are
wrong? ✔✔Fraud
Which of the following is NOT potentially a penalty for violation of a law or regulation
prohibiting Fraud, Waste, and Abuse (FWA)? ✔✔Deportation
A person comes to your pharmacy to drop off a prescription for a beneficiary who is a “regular”
customer. The prescription is for a controlled substance with a quantity of 160. This beneficiary
normally receives a quantity of 60, not 160. You review the prescription and have concerns
about possible forgery. What is your next step? ✔✔Call the prescriber to verify the quantity
Your job is to submit a risk diagnosis to the Centers for Medicare & Medicaid Services (CMS)
for the purpose of payment. As part of this job you verify, through a certain process, that the data
is accurate. Your immediate supervisor tells you to ignore the Sponsor’s process and to
adjust/add risk diagnosis codes for certain individuals. What should you do? ✔✔Report the
incident to the compliance department (via compliance hotline or other mechanism
AHIP general compliance questions and
answers already passed
Compliance is the responsibility of the compliance officer, compliance committee and upper
management only ✔✔False
Ways to report a compliance issue include ✔✔All of the above
What is the policy of non-retaliation ✔✔Protects employees who, in good faith, report suspected
non-compliance
These are examples of issues that can be reported to a compliance department :suspected fraud,
waste, and abuse; potential health privacy violation and unethical behavior/employee misconduct
✔✔True
Once a corrective action plan begins addressing non compliance or fraud, waste and abuse
committed by a sponsors employee or first tier, downstream, or related entity’s (fdr’s) employee,
ongoing monitoring or the corrective actions is not necessary ✔✔False
Medicare parts c and d plan sponsors are not required to have a compliance program ✔✔False