Ch. 07 (Qs) - Health Care Fraud

Front 1

Which of the following situations can constitute Healthcare fraud committed by an insurance company?

A. Submitting cost data to healthcare Regulators to justify rate increases

B. Failing to follow procedures to detect fraudulent claims when acting as an intermediary for another insurance program

C. Failing to pay a claim because the claim is missing required information

D. All of these answers are correct

Back 1

Failing to follow procedures to detect fraudulent claims when acting as an intermediary for another insurance program

Front 2

Special Care Facilities generally have the capability to meet all of their patients needs without the services of outside providers, leading to a lower likelihood of fraud involving such institutions.

Back 2

False

Front 3

Michael, a medical provider, performs an appendectomy, a procedure that is supposed to be billed as one code. Instead, he intentionally submit stew codes for the same procedure, one for an abdominal incision and one for removal of the appendix. Which of the following best describes Michaels scheme?

Back 3

Unbundling

Front 4

Falsified prescriptions for equipment, excessive supplies, non-covered supplies, and scooter scams are forms of fraud, involving what type of healthcare entity?

Back 4

Reusable medical equipment suppliers

Front 5

Common methods of inflating Healthcare Billings include all of the following except:

A. Sliding policies

B. Added services

C. Code manipulation

D. Altered claims

Back 5

Sliding policies

Front 6

It is very difficult to alter automated insurance or health care claims.

Back 6

False

Front 7

Fraudulent Kickbacks in the healthcare industry can include which of the following?

A. Payment for referral of patients

B. Payment for additional medical coverage

C. Waiver of deductibles and co-payments

D. All of these answers are correct

Back 7

All of these answers are correct

Front 8

Special care facilities are generally at a greater risk of Health Care fraud than other medical institutions.

Back 8

True

Front 9

When a medical provider performs a service for a patient the bills the patient's insurer for a more complex and more expensive service, this practice is called

Back 9

Upcoding

Front 10

_____ involve paying individuals to undergo unnecessary medical procedures that are then billed to the patient's insurer for healthcare program.

Back 10

Rent a patient schemes

Front 11

In a Managed Care environment, insured fraud might be reduced, but provider fraud is still very common.

Back 11

True

Front 12

Which of the following statements concerning fraud involving Special Care Facilities is true?

A. Many patients in special care facilities are less likely to report fraud because they are often not responsible for their own financial affairs.

B. When fraud is committed against Special Care Facilities, it is common for victims to obtain repayment from the perpetrators.

C. It is difficult for fraud in Special Care Facilities to be committed in high-volume because patients are located in close proximity to each other.

D. All of these answers are correct

Back 12

Many patients in special care facilities are less likely to report fraud because they often are not responsible for their own financial affairs

Front 13

Which of the following Health Care frauds would be best described as a fictitious provider scheme?

A. A thief steals a healthcare providers identifier and bills a government Healthcare program under the name of a fake Clinic.

B. A doctor at a hospital inflates the cost of his Services by coating them as being more complex than they should be.

C. A group of people posing as medical professionals provide services without proper licenses.

D. A provider operates a mobile lab that bills a Health Care Program for Unnecessary tests and then relocates.

Back 13

A thief steals a healthcare providers identifier and bills a government Healthcare program under the name of a fake Clinic

Front 14

Which of the following Health Care frauds would be best described as a fictitious Services scheme?

A. A patient fraudulently reports symptoms he's not have to receive a prescription.

B. Doctor intentionally submit a bill to an insurer using improper codes for the services provided.

C. A patient who is not insured pretends to be an insured party to receive Medical Services.

D. A doctor uses the identifying information of patients he has never serviced to Bill an insurer.

Back 14

A doctor uses the identifying information of patients he has never serviced to Bill an insurer

Front 15

Which of the following is a common scheme perpetrated by suppliers of reusable medical equipment?

A. Billing for equipment rental after it is returned.

B. Falsifying prescriptions for medical equipment.

C. Providing a poorer quality wheelchair or scooter than build for.

D. All of these answers are correct

Back 15

All of these answers are correct

Front 16

An insurance company might be guilty of fraud if it fails to pass on the fee breaks it negotiates with its providers to its customers.

Back 16

True

Front 17

Examples of fraud schemes perpetrated by Healthcare institutions and their employees include all of the following except:

A. Billing for experimental procedures

B. Unintentional misrepresentation of the diagnosis

C. Improper contractual relationships

D. Drg creep

Back 17

Unintentional misrepresentation of the diagnosis

Front 18

Billing for experiments with new medical devices that have not yet been approved by a jurisdictions healthcare Authority is one form of medical fraud.

Back 18

True

Front 19

Samantha operates a medical lab from a Mobile Trailer. Her business model is to go to an area, recruit patients for a battery of unnecessary tests, and build Health Care programs for those tests. She also typically bills for services never actually performed using the patient data collected. Soon after, she moves the trailer to a new location and start the process again. Samantha scheme is known as a...

Back 19

Rolling lab

Front 20

To detect provider fraud, a fraud examiner should be alert for which of the following red flags?

I. Pressure for Rapid processing of claims

II. Frequent telephone inquiries on claim status

III. No supporting documentation for charges

IV. Patients address on the claim form is the same as the providers

Back 20

I, II, III, and IV

Front 21

A healthcare providers practice of charging a comprehensive code, as well as one or more component codes, by billing separately for sub-components of a single procedure is known as _____.

Back 21

Unbundling

Front 22

If a person is convicted of a federal health care offense in the United States, the judge can order the person forfeit any property that can be traced from the proceeds received from the offense.

Back 22

True

Front 23

Health care providers in the United States use current procedural terminology (CPT) codes to identify inpatient and outpatient procedures performed.

Back 23

True

Front 24

All of the following are types of medical provider fraud except:

A. Fictitious providers

B. Smurfing

C. Rolling labs

D. Fictitious services

Back 24

Smurfing

Front 25

A hospital has a pattern of incorrectly coding and documenting minor cuts and scratches as major lacerations, this is an example of _____ _____.

Back 25

DRG Creep

Front 26

Lindsey, a medical provider, provides monetary payments to existing patients into other providers for referring new patients to her practice. What is the name of Lindsay's scheme?

Back 26

Kickback

Front 27

A medical provider billed an insurance company for a name brand drug, while providing the patient with a generic version of the drug. This inflated billing scheme is known as which of the following?

A. Undercharging

B. Unbundling

C. Upcoding

D. Replacement fraud

Back 27

Upcoding

Front 28

Which of the following can best be described as fraud perpetrated by medical practitioners, medical suppliers, or medical institutions on patient or Healthcare programs to increase their own income by illicit means?

A. Insurer fraud

B. Beneficiary fraud

C. Provider fraud

D. Uncovered party fraud

Back 28

Provider fraud

Front 29

With the health insurance portability and accountability Act of 1996, the US Congress added which of the following offenses to the federal code?

A. Theft or embezzlement in connection with health care

B. False statement relating to Health Care fraud

C. Committing fraud against Healthcare benefit programs

D. All of these answers are correct

Back 29

All of these answers are correct

Front 30

DRG creep occurs when staff members at Medical institutions intentionally manipulate Diagnostic and procedural codes in a pattern to increase claim reimbursement amounts.

Back 30

True

Front 31

Heidi, a certified fraud examiner and internal auditor for a Health Care Program, has been asked to review the program's system of internal controls in the claims processing area. Heidi has decided to present the management of the unit with a list of General indicators for fraud that are applicable to many health insurance fraud schemes by program beneficiaries. All of the following would be included on Heidi's list except:

A. Anonymous telephone or email inquiries regarding the status of a pending claim

B. Threats of legal action when a claim is not paid quickly

C. Individuals who mail their claim and ask for their claim payment to be sent through direct bank transfer

D. Pressure by a claimant pay a claim quick

Back 31

Individuals who mailed their claim and ask for their claim payment to be sent through direct bank transfer

Front 32

Why is the healthcare industry concerned about the potential effect of the electronic data interchange (EDI) on fraudulent activity?

A. The tools required to detect EDI fraud are difficult to use.

B. Only a few types of healthcare transactions can be processed by EDI.

C. The efficiency of EDI allows for more vendors and thus more claims to process.

D. All of these answers are correct

Back 32

The efficiency of EDI allows for more vendors and thus more claims to process