Health Care Fraud Flashcards
An insurance company might be guilty of fraud if it negotiates discounts with its medical providers and fails to apply those discounts to its consumers.
A. True
B. False
True
Which of the following scenarios is an example of a multiple claims health care fraud scheme as perpetrated by a patient?
A. Julia uses a stolen government identification number to impersonate a stranger and obtain medical services for herself.
B. James visits several local emergency rooms and falsely claims to have severe back pain in an effort to obtain prescription pain medication.
C. Roberta files medical claims with her ex-husband’s private insurer even though the divorce makes her ineligible for benefits under the policy.
D. Bill obtains double reimbursement for his hip replacement surgery by filing claims with different insurers.
D. Bill obtains double reimbursement for his hip replacement surgery by filing claims with different insurers.
A doctor provides services to both patients who pay directly and patients whose bills are paid by a government program. To make the services more attractive to patients outside the coverage of the government program, the doctor gives patients who pay directly a discount that is not applicable to patients under the program. Which of the following BEST describes the provider’s scheme?
A. Disparate price
B. Fictitious claim
C. Upcoding
D. Overutilization
A. Disparate price
Which of the following is NOT a red flag of health care provider fraud?
A. Medical records that were created long after the alleged patient visit
B. Details in supporting documents that are inconsistent with the claim
C. Lack of supporting documentation for claims under review
D. Consistently low percentage of coding outliers present
D. Consistently low percentage of coding outliers present
All the following are types of medical provider fraud EXCEPT:
A. Fictitious providers
B. Clinical lab schemes
C. Fictitious services
D. Smurfing
D. Smurfing
___________ involve paying an individual to undergo unnecessary medical procedures that are then billed to the patient’s insurer or health care program.
A. Rent-a-patient schemes
B. DRG creep schemes
C. False cost reporting schemes
D. Fictitious patient schemes
A. Rent-a-patient schemes
A patient goes to the doctor for a medical condition. The doctor identifies the condition but decides to order additional lab testing even though it is unnecessary. The patient is sent to a lab owned by the same doctor, so the doctor will profit from the unnecessary testing. Which of the following BEST describes the doctor’s scheme?
A. Front organization
B. Clinical lab
C. Rolling lab
D. Fictitious provider
B. Clinical lab
Which of the following statements concerning fraud that involves 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 to commit fraud in high volume in special care facilities because patients are located in close proximity to each other
D. All of the above
A. Many patients in special care facilities are less likely to report fraud because they are often not responsible for their own financial affairs
After purchasing an insured’s government identification number on the dark web, a fraudster pretends to be the insured and obtains medical care under the insured’s health insurance policy. This patient health care fraud scheme can BEST be described as misrepresentations fraud.
A. True
B. False
False
All the following are health care fraud schemes that are commonly perpetrated by patients EXCEPT:
A. Third-party fraud
B. Doctor shopping
C. Multiple claims fraud
D. Over-utilization
D. Over-utilization
When a medical provider performs a service for a patient but bills the patient’s health care program for a more complex and more expensive service, this practice is called upcoding.
A. True
B. False
True
Which of the following health care frauds would BEST be described as a fictitious services scheme?
A. A patient fraudulently reports symptoms they do not actually have to receive a prescription.
B. A doctor intentionally submits a bill to an insurer or health care program using improper codes for the services provided.
C. A patient who is not covered under a health care program pretends to be a covered party to receive medical services.
D. A doctor uses the identifying information of patients the doctor has never serviced to bill an insurer or health care program.
D. A doctor uses the identifying information of patients the doctor has never serviced to bill an insurer or health care program.
Examples of fraud schemes perpetrated by health care institutions and their employees include all the following EXCEPT:
A. Billing for experimental procedures
B. Improper contractual relationships
C. Unintentional misrepresentation of the diagnosis
D. DRG creep
C. Unintentional misrepresentation of the diagnosis
Which of the following is a common scheme perpetrated by suppliers of durable medical equipment (DME)?
A. Falsifying prescriptions for medical equipment
B. Intentionally providing excessive equipment
C. Billing for equipment rental after it is returned
D. All of the above
D. All of the above
Which of the following health care frauds would BEST be described as a fictitious provider scheme?
A. A group of people posing as medical professionals provide services without proper licenses.
B. A thief steals a health care provider’s identification information and bills a government health care program under the name of a fake clinic.
C. A doctor at a hospital inflates the cost of services by coding them as being more complex than they should be.
D. A provider operates a mobile lab that bills a health care program for unnecessary tests and then relocates.
B. A thief steals a health care provider’s identification information and bills a government health care program under the name of a fake clinic.
