October 23, 2025 Claire B 0 Comments

  1. An insurance company did not follow applicable rules when setting rates it charged for healthcare benefits under its Federal Employees health Benefits Program (FEHBP) contracts, and failed to give the healthcare program the same discounted rates it gave similarly situated commercial customers. It also failed to coordinate FEHBP benefits with those provided to Medicare eligible annuitants and submitted statements to the Office of Personnel Management (OPM) that failed to fully disclose rate adjustments due to FEHBP.
  3.
  6. 1 points

Question 2


  1. The state of California and the county of Los Angeles billed Medicaid for services provided to minors when those jurisdictions had no basis for concluding that these individuals financially qualified for Medicaid services. The services at issue in this matter were treatment for drug and alcohol abuse, pregnancy and pregnancy-related services, family planning, sexual assault treatment, sexually transmitted diseases treatment, and mental health services.

1 points

Question 3


  1. The provider prescribed a medication for 30 days with a refill when it is not known if the medication will be needed.

1 points

Question 4


  1. A physician documented the medical necessity of a number of medical supplies for a patient’s care in the office. Upon review, Medicare denied reimbursement for the claim, stating that the number of medical supplies ordered was excessive.

1 points

Question 5


  1. A medical assistant administered the influenza vaccine during the office’s flu clinic and the physician billed for the services for each patient.

1 points

Question 6


  1. A durable medical company provided monetary incentives to physician offices for referrals of patients to increase revenue.

1 points

Question 7


  1. A pediatrician sees a patient for a well-child visit but knows the patient’s insurance plan does not cover the preventative code and bills for an established patient visit instead.

1 points

Question 8


  1. An insurance company failed to process Medicare claims properly, and then submitted false information to CMS regarding the accuracy of and the timeliness with which it had handled those claims.

1 points

Question 9


  1. A chiropractor performed ultrasonography to follow the progress of a patient treated for back pain. Medicare denied the payment because it determined that this was not a legitimate use for ultrasonography

1 points

Question 10


  1. A patient asks the physician to restate a diagnosis so the insurance company will pay because payment would be denied based on the present statement. The physican complies with the request.

1 points

Question 11


  1. A provider ordered a number of the same laboratory tests on several different patients, carefully documenting the medical necessity of each. Upon review, Medicare determined that half of the patients did not need to have those tests performed, and reimbursement was denied.

1 points

Question 12


  1. A pharmacist fills a prescription for the brand name of the drug instead of the generic form that was available and submits the claim to the insurance carrier.

1 points

Question 13


  1. An ambulance company submitted claims for reimbursement to Medicare for services clients that were deceased.

1 points

Question 14


  1. Pharmaceutical company promotes unapproved “off label” uses of its drugs, inflating prices, and paying kickbacks to doctors and pharmacies to purchase its products.

1 points

Question 15


  1. A physician (unaware of the generic alternative) consistently prescribes a high priced medication for his patients instead of the less expensive drug available in the formulary.

1 points

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