AHIP TRAINING MEDICARE FRAUD, WASTE,
AND ABUSE TRAINING WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS
RATED A+
Civil monetary penalties CMP's Correct Answer Penalties that
may be imposed for a variety of conduct including Medicare FWA.
Different amts. of penalties and assessments may be authorized
based on the type of violation and can range as high as $50,000
per violation.
Example: Presenting a claim that a person knows or should know
is for a service that was NOT provided as claimed or is false and
fraudulent.
Pharmacy benefits manager Correct Answer **A company that
administers the prescription drug benefit program of a health plan
or employer.
**PBMs process and pay prescription drug claims and are often
responsible for creating and updating formularies.
**PBMs buy medications in large quantities from drug
manufacturers and are therefore able to obtain and offer
discounts.
Special investigation unit Correct Answer **A unit of a health plan
(often separate from the compliance office) dedicated to
combating FWA.
**It is frequently staffed by former law enforcement personnel,
such as veterans of the FBI.
**SIUs have traditionally focused their investigations on third-party
claims submitted to health plans.
**In the case of MA and Part D plans, however, the scope of SIU
investigations is likely to include identification of suspected FWA
, committed by subcontractors involved in the delivery of the MA or
PDP benefits.
The Scope of Healthcare FWA Correct Answer **As a nation, we
spend over $2.7 trillion on Healthcare every year, and it is
estimated that tens of billions are lost each year to FWA.
**One recent study estimated that fraud and abuse added as
much as $98 billion to annual spending on Medicare and
Medicaid.
Combating FWA: A Health Plan Priority Correct Answer
**Medicare plans also recognize the seriousness of FWA, which
not only result in lost dollars but can jeopardize the quality of
healthcare received by plan enrollees.
**Health plans seek your help in combating FWA and this training
is designed to help you recognize questionable activity and take
steps to stop or prevent it.
The Human Cost of FWA: An example Correct Answer **As
mentioned, FWA is not only costly, it can have serious
implications for the health of Medicare plan enrollees.
**Member has card stolen and used by someone else for Rx's
and other medical treatments; therefore member is unable to get
her Rx's renewed. Member goes w/o her meds and has a minor
stroke. Now her health records are not accurate.
Example of Fraud Committed by a Pharmacist Correct Answer
When Pharmacist James Wilson fills Rx's for pain relievers, he
deliberately puts fewer pills in the bottle than the prescribed
number. His customers usually don't notice or think they have
miscounted. James keeps the extra pills and sells them to a local
drug dealer.
Examples of Fraud by Agents and Brokers Correct Answer
**Agents and brokers involved in the sale of Medicare plans can
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller wachiraMaureen. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $20.47. You're not tied to anything after your purchase.
