2019 fraud, waste, and abuse external training, quiz, and ......published by articulate® storyline...

Published by Articulate® Storyline www.articulate.com

2019 Fraud, Waste, and Abuse_External Training, Quiz, and Key

1. Welcome

1.1 Combating Medicare Parts C and D Fraud, Waste, and Abuse (FWA)


2. Training Overview

2.1 Training Overview



Note: For paper versions of the training, the Key Terms and Acronyms resource is located at the

end of this document.


3. Lesson 1

3.1 Lesson 1: What is FWA?


3.26 Lesson 1 Knowledge Check

Correct Choice

X A. Fraud

B. Waste

C. Abuse


Correct Choice

A. Civil Monetary Penalties

X B. Deportation

C. Exclusion from participation in all Federal health care programs


4. Lesson 2

4.1 Lesson 2: Your Role in the Fight Against FWA


4.25 Lesson 2 Knowledge Check

Correct Choice

A. Fill the prescription for 160

B. Fill the prescription for 60

X C. Call the prescriber to verify the quantity

D. Call the Sponsor’s compliance department

E. Call law enforcement


Correct Choice

A. Do what your immediate supervisor asked you to do and adjust or add

risk diagnosis codes

X 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


Correct Choice

A. Call Doe Diagnostics and request additional information for the claims

X B. Consult with your immediate supervisor for next steps or contact the

compliance department (via compliance hotline, Special Investigations

Unit, or other mechanism)

C. Reject the claims

D. Pay the claims


Correct Choice

A. Call local law enforcement

B. Perform another review

C. Contact your compliance department (via compliance hotline or other

mechanism)

D. Discuss your concerns with your supervisor

X E. Follow your pharmacy’s procedures


5. Post-assessment

5.1 Post-assessment


5.2 Post-assessment


Question 1 of 10

Correct Choice

True

X False


Question 2 of 10

Correct Choice

A. Telephone hotlines

B. Mail drops

C. In-person reporting to the compliance department/supervisor

D. Special Investigations Units

X E. All of the above


Question 3 of 10

Correct Choice

True

X False


Question 4 of 10

Correct Choice

X True

False


Question 5 of 10

Correct Choice

X True

False


Question 6 of 10

Correct Choice

X True

False


Question 7 of 10

Correct Choice

X True

False


Question 8 of 10

Correct Choice

X True

False


Question 9 of 10

Correct Choice

X True

False


Question 10 of 10

Correct Choice

A. Civil Monetary Penalties

B. Imprisonment

C. Exclusion from participation in all Federal health care programs

X D. All of the above


5.14 Prime Therapeutics’ Reporting Methods


5.15 Thank you for completing the course!


Acronyms

AIDS: Acquired Immune Deficiency Syndrome

CFR: Code of Federal Regulations

CMP: Civil Monetary Penalties

CMS: Centers for Medicare & Medicaid Services

DME: Durable Medical Equipment

DMEPOS: Durable Medical Equipment, Prosthetics, Orthotics and Supplies

DOJ: Department of Justice

EPLS: Excluded Parties List System

FCA: False Claims Act

FDR: First-tier, Downstream, and Related Entity

FEP: Federal Employee Program

FWA: Fraud, Waste, and Abuse

GSA: General Services Administration

HHS: U.S Department of Health & Human Services

HIPAA: Health Insurance Portability and Accountability Act

LEIE: List of Excluded Individuals and Entities

MA: Medicare Advantage

MAC: Medicare Administrative Contractor

MA-PD: Medicare Advantage Prescription Drug

MAO: Medicare Advantage Organizations

NBI MEDIC: National Benefit Integrity Medicare Drug Integrity Contractor

NPI: National Provider Identifier

OIG: Office of Inspector General

PBM: Pharmacy Benefit Manager

PDP: Prescription Drug Plan

SAM: System for Award Management

SDP: Self-Disclosure Protocol

SIU: Special Investigations Unit


Key Terms

Abuse: Abuse includes actions that may, directly or indirectly, result in: unnecessary costs to the

Medicare Program, improper payment, payment for services that fail to meet professionally

recognized standards of care, or services that are medically unnecessary. Abuse involves

payment for items or services when there is no legal entitlement to that payment and the provider

has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be

differentiated categorically from fraud, because the distinction between “fraud” and “abuse”

depends on specific facts and circumstances, intent and prior knowledge, and available evidence,

among other factors.

Fraud: Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice

to defraud any health care benefit program or to obtain, by means of false or fraudulent pretenses,

representations, or promises, any of the money or property owned by, or under the custody or

control of, any health care benefit program. Fraud is intentionally submitting false information to

the Government or Government contractor to get money or a benefit.

Medicare Part C: Medicare Part C, or Medicare Advantage (MA), is a health insurance option

available to Medicare beneficiaries, run by private, Medicare-approved insurance companies.

These companies arrange for, or directly provide health care services to the beneficiaries who

enroll in an MA plan. MA plans must cover all services that Medicare covers with the exception of

hospice care. They provide Part A and Part B benefits and may also include prescription drug

coverage and other supplemental benefits.

Medicare Part D: Medicare Part D, the Prescription Drug Benefit, provides prescription drug

coverage to Medicare beneficiaries enrolled in Part A and/or Part B who enroll in a Medicare

Prescription Drug Plan (PDP) or an MA Prescription Drug (MA-PD) plan. Medicare-approved

insurance and other companies provide prescription drug coverage to individuals living in a plan’s

services area.

Waste: Waste is the overutilization of services, or other practices that, directly or indirectly, result

in unnecessary costs to the Medicare program. Waste is generally not considered to be caused

by criminally negligent actions but rather by the misuse of resources.


Whistleblower: A whistleblower is a person who exposes information or activity that is deemed

illegal, dishonest, or violates professional or clinical standards.

2019 fraud, waste, and abuse external training, quiz, and ......published by articulate® storyline...

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