Medicare Fraud, Waste, & Abuse (2022/2023) (Certified Answers)

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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 th... is 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 You are performing a regular inventory of the controlled substances in the pharmacy. You discover a minor inventory discrepancy. What should you do? a.Perform another review b.Follow your pharmacy's procedures. c.Call local law enforcement d.Discuss your concerns with your supervisor e.Contact your compliance department (via compliance hotline or other mechanism) ✔✔Follow your pharmacy's procedures. You are in charge of paying claims submitted by providers. You notice a certain diagnostic provider ("Doe Diagnostics") requested a substantial payment for a large number of members. Many of these claims are for a certain procedure. You review the same type of procedure for other diagnostic providers and realize Doe Diagnostics' claims far exceed any other provider you reviewed. What should you do? a.Call Doe Diagnostics and request additional information for the claims b.Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) c.Pay the claims d.Reject the claims ✔✔Consult with your immediate supervisor for next steps or contact the compliance department (via compliance hotline, Special Investigations Unit [SIU], or other mechanism) You discover an unattended email address or fax machine in your office receiving beneficiary appeals requests. You suspect no one is processing the appeals. What should you do? a.Wait to confirm someone is processing the appeals before taking further action b.Contact your compliance department (via compliance hotline or other mechanism) c.Nothing d.Contact your supervisor e.Contact law enforcement ✔✔Contact your compliance department (via compliance hotline or other mechanism) A sales agent, employed by the Sponsor's first-tier, downstream, or related entity (FDR), submitted an application for processing and requested two things: 1) to back-date the enrollment date by one month, and 2) to waive all monthly premiums for the beneficiary. What should you do? a.Contact law enforcement and the Centers for Medicare & Medicaid Services (CMS) to report the sales agent's behavior b.Process the application properly (without the requested revisions)—inform your supervisor and the compliance officer about the sales agent's request c.Tell the sales agent you will take care of it but then process the application properly (without the requested revisions)—you will not file a report because you don't want the sales agent to retaliate against you d.Refuse to change the date or waive the premiums but decide not to mention the request to a supervisor or the compliance department e.Make the requested changes because the sales agent determines the beneficiary's start date and monthly premiums ✔✔Process the application properly (without the requested revisions)— inform your supervisor and the compliance officer about the sales agent's request You work for a Sponsor. Last month, while reviewing a Centers for Medicare & Medicaid Services (CMS) monthly report, you identified multiple individuals not enrolled in the plan but for whom the Sponsor is paid. You spoke to your supervisor who said don't worry about it. This month, you identify the same enrollees on the report again. What should you do? a.Decide not to worry about it as your supervisor instructed—you notified your supervisor last month and now it's his responsibility b.Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting—to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification c.Wait until the next month to see if the same enrollees appear on the report again, figuring it may take a few months for CMS to reconcile its records—if they are, then you will say something to your supervisor again d.Ask your supervisor about the discrepancy again e.Contact law enforcement and CMS to report the discrepancy ✔✔Although you know about the Sponsor's non-retaliation policy, you are still nervous about reporting—to be safe, you submit a report through your compliance department's anonymous tip line to avoid identification [Show More]

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