NCICS Healthcare Fraud, Waste & Abuse Prevention 2

Question 1

The Anti-Kickback Statute (AKS) prohibits which of the following activities?

Accepted Answer

Offering or receiving anything of value to induce or reward referrals for services covered by federal healthcare programs

Answer

Physicians referring patients to other medical specialties

Answer

Billing Medicare for services not covered under the patient's benefit plan

Answer

Using unlicensed staff to provide medical services

Question 2

A hospital bills Medicare separately for each component of a complex procedure—such as the procedure itself, radiologist interpretation, and supplies—when a single comprehensive CPT code should cover all components. This is known as:

Accepted Answer

Unbundling

Answer

Upcoding

Answer

Downcoding

Answer

Double billing

Question 3

A 'qui tam' lawsuit filed under the False Claims Act allows:

Accepted Answer

Private citizens to file suit on behalf of the government and share in any financial recovery

Answer

The government to sue healthcare providers directly without evidence

Answer

Patients to sue for medical malpractice in federal court

Answer

Insurance companies to recover overpayments from providers

Question 4

Recovery Audit Contractors (RACs) are primarily designed to:

Accepted Answer

Identify and recover improper Medicare and Medicaid payments after they have been made

Answer

Approve prior authorization requests before services are rendered

Answer

License healthcare providers to participate in Medicare

Answer

Process Medicare claims for timely payment to providers

Question 5

A provider submits the same claim to Medicare twice for a single patient visit that occurred only once. This is an example of:

Accepted Answer

Double billing

Answer

Upcoding

Answer

Unbundling

Answer

Churning

Question 6

'Churning' in the context of healthcare fraud refers to:

Accepted Answer

Performing medically unnecessary repeat procedures or visits primarily to generate additional billing

Answer

Submitting claims for services performed by unlicensed staff

Answer

Billing for services provided by a different provider than the one listed on the claim

Answer

Using incorrect diagnosis codes to justify additional procedures

Question 7

When a healthcare organization identifies that it has received a Medicare overpayment, it must report and return the overpayment within:

Accepted Answer

60 days of identification

Answer

30 days of identification

Answer

90 days of identification

Answer

180 days of identification