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2024 AHIP TRAINING MEDICARE FRAUD, WASTE, AND ABUSE TRAINING EXAM WITH ANSWERS
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2024 AHIP TRAINING MEDICARE FRAUD, WASTE, AND ABUSE TRAINING EXAM WITH ANSWERS
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2024 AHIP TRAINING MEDICAREFRAUD, WASTE, AND ABUSE
TRAINING EXAM WITH ANSWERS
Medicare plan means - CORRECT-ANSWERSA MA plan, MA-PD plan or PDP
Legal Tools Against FWA (to Combat FWA) - CORRECT-ANSWERSThere are
several legal tools that the government can employ in its fight against FWA,
including the following statutes:
1. Federal Civil False Claims Act
2. Anti-Kickback Statute
3. Physician Self-Referral Law (Stark Legislation)
4. Criminal Health care Fraud Statute
5. Criminal False Statements Act
6. HIPPA and HITECH Act
**Violations of these laws can result in non-payment of claims, imposition of
CIVIIL MONETARY PENALTIES, exclusions from the Medicare program,
imprisonment and criminal and civil liability.
The Federal Civil False Claims Act.
Criminal False Statements Act
**The US code provides that anyone who falsifies or conceals a material fact,
makes materially false statements or representations, or uses any false
documents knowing them to contain false statements in any matter within
the jurisdiction of the Executive Branch, which includes CMS, shall be fined
and imprisoned for up to 5 years.
**It would be a violation of this law if independent agents knowingly provide
MA and Part D plans with false information that they know will be provided to
CMS - CORRECT-ANSWERS**The federal false claims act PROHIBITS
individuals and entities from knowingly presenting a false or fraudulent claim
or a statement in support of a false or fraudulent claim to the federal
government for payment or approval.
**Liability under the Federal Civil False Claims Act now extends to
subcontractors who submit claims for reimbursement to government
contractors, including Medicare plans.
**The penalties for submitting false claims can be severe; they can include
triple damages and fines.
**Those who submit false or fraudulent claims to the Federal Government,
including Medicare claims, or who participate in such submissions can be
held personally liable for their actions.
, **Additionally, individual states may have their own false claims act and
similar penalties (e.g. Florida False Claims Act)
Examples of False claims - CORRECT-ANSWERS**A pharmacy consistently
bills a MA plan for more pills than are actually dispensed to the plan's
enrollees.
**A physician knowingly submits claims for services never provided to
Medicare enrollees.
Federal Anti-Kickback Statute
Example: Billco Pharmacy waives Medicare Part D copayments for certain
drugs to encourage Part D enrollees to fill their Rx's there. - CORRECT-
ANSWERSThe Federal Anti-Kickback Statute makes it a criminal offense to
knowingly and willfully offer, pay, solicit, or receive any remuneration to
induce or reward referrals of items or services reimbursable by the Federal
Healthcare program, including Medicare.
**Remuneration includes anything of value in cash or in kind. The anti-
kickback regulations do provide safe harbors. If a payment arrangement fits
within these safe harbors it is NOT treated as a violation of the law.
**Penalties: Fines of up to $25,000, imprisonment up to 5 years, or both.
Example of Physician Self-Referral Law (Stark Law) - CORRECT-ANSWERSDr.
Frances Winters refers her patients needing routine blood tests to an outside
independent laboratory that is owned by her husband.
**Penalties for physicians who violate the Stark Law includes fines as well as
exclusion from participation in ALL Federal healthcare programs, including
Medicare.
Civil Monetary Penalties - CORRECT-ANSWERSThe SS Act (which governs
Medicare) authorizes civil monetary penalties when CMS or other federal
authorities determine that an individual or entity has violated Medicare rules
or regulations.
**CMP's can be large--for instance, a health plan might be assessed $25,000
for each MA enrollee adversely impacted.
Exclusion from Medicare Program - CORRECT-ANSWERS**Violations of
Medicare rules and regulations can also lead to exclusion from the Medicare
program.
**A healthcare provider's Medicare ID# and privilege of providing services to
Medicare beneficiaries can be revoked.
**Given the size and extent of the Medicare program, this can substantially
limit a provider's future income and employment opportunities.
**Also, an agent that is excluded from the Medicare program could NOT sell
coverage under MA or Part D as well as any other federal healthcare
programs.
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