CFE – Financial Transactions and Fraud Schemes — Question 54

After a government health care program pays for Marco’s appendectomy, he files a claim for reimbursement under his private insurance policy for the same procedure. Which type of patient-perpetrated health care fraud scheme is Marco MOST LIKELY committing?

Answer options

• A. Misrepresentations scheme
• B. Ineligible claimants scheme
• C. Fictitious claims scheme
• D. Multiple claims scheme

Correct answer: A

Explanation

Marco is likely committing a Misrepresentations scheme because he is attempting to claim reimbursement for a service that has already been paid for by another entity. The other options do not apply; Ineligible claimants refer to individuals not entitled to benefits, Fictitious claims involve non-existent services, and Multiple claims pertain to submitting the same claim to multiple insurers without prior payment.