AHFI Examination Prep Course Exam
Questions With Correct Answers
HCF Investigator Assumptions - CORRECT ANSWER✔✔-*General knowledge of
| | | | | | | |
the Health care Delivery System
| | | |
*Health plan policy and procedures relative to the delivery of services
| | | | | | | | | |
*Able to identify Red Flags, behaviors & indicators of health care fraud schemes
| | | | | | | | | | | |
Know applicable federal & state laws related to health care fraud
| | | | | | | | | |
*Law enforcement & regulatory agencies that have oversight responsibilities for
| | | | | | | | | |
HCF
*Local & regional investigative groups that have similar interests
| | | | | | | |
Fraud, by it's very nature, is decptive. - CORRECT ANSWER✔✔-As such, nobody
| | | | | | | | | | | |
really knows what the impact and cost of fraud is. However there are some
| | | | | | | | | | | | | |
common industry estimates | |
Conservative US Healthcare spending in 2015 was $3.2Trillion
| | | | | | |
,Conservative estimate of fraud is 3-5% (means tens of billions of dollars each
| | | | | | | | | | | | |
year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between 5% and
| | | | | | | | | | | | | | |
10%)
Anatomy of an investigation - CORRECT ANSWER✔✔-Each fraud case is unique,
| | | | | | | | | | |
however, under the surface of the specific schemes, all HCF investigatons have a
| | | | | | | | | | | | |
common structure, or process.
| | |
Anatomy of an investigation - 1) Detection - CORRECT ANSWER✔✔-The process
| | | | | | | | | | |
of uncovering potential fraud waste and abuse utilizing human and technical
| | | | | | | | | | |
resources and techniques
| |
Anatomy of an investigation - 2) Assessment - CORRECT ANSWER✔✔-The primary
| | | | | | | | | |
|objective of the assessment phase is to establish PREDICATION for the continued
| | | | | | | | | | | |
investigation
Predication - CORRECT ANSWER✔✔-to proclaim; declare; assert
| | | | | |
Anatomy of an Investigation - 3) Investigative Strategy - CORRECT ANSWER✔✔-
| | | | | | | | | |
Devoloping an investigative plan to identify and gather evidence to support the
| | | | | | | | | | | |
statuatory elements to prove
| | |
Anatomy of an investigation - 4) Case Investigation - CORRECT ANSWER✔✔-The
| | | | | | | | | | |
process of utilizing legal and appropriate techniques to prove or disprove the
| | | | | | | | | | | |
allegations
,Antomy of an investigation - 5) Report Writing - CORRECT ANSWER✔✔-The
| | | | | | | | | | |
process of documenting the investigative tasks in a final comprehensive
| | | | | | | | | |
investigative report. |
Anatomy of an investigation - 6) Determination of action - CORRECT ANSWER✔✔-
| | | | | | | | | | |
Evaluating the totality of the documented case facts to determine the best action
| | | | | | | | | | | | |
to resolve the investigation.
| | |
Anatomy of an investigation - 1) Detection - Case Management - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-Includes:
*Behavioral & Pattern Analysis | | |
Emergings Schemes - being familiar enough with new schemes to be able to
| | | | | | | | | | | | |
recognize that something is "off"
| | | |
"Hot Spots": Know where the "hot-spots" are in the country
| | | | | | | | |
The top Red Flags for Health Care Fraud in 2018 - CORRECT ANSWER✔✔-1)
| | | | | | | | | | | | |
Opioids: 12 hotspots (Florida, Tennessee, Alaska, Texas); focus investigations and
| | | | | | | | | |
prosecuting "pill mills" (pharmacies that improperly divert and dispense Rx opioid
| | | | | | | | | |
and other opioid-related issues)
| | | |
2) Home Health Care:
| | | |
, 3) Use of data:
| | | |
4) Robosigning: Involves a doctor blindly writing Rx or order that authorize care
| | | | | | | | | | | | |
without first making an individualized determination of medical necessity.
| | | | | | | |
5) Kickbacks:
| |
6) Upcoding: The improper practice of a medical professional billing for a more
| | | | | | | | | | | | |
expensive medical service than was actually provided to the patient. The DOJ
| | | | | | | | | | | |
focuses on service-based, location-based or time-based upcoding
| | | | | |
7) Billing for unqualified workers:
| | | |
Upcoding - CORRECT ANSWER✔✔-The DOJ focuses on service-based, location-
| | | | | | | |
based and/or time-based upcoding
| | |
Service-based upcoding: A doctor may perform a simple check-up, but bill for a
| | | | | | | | | | | | |
more extensive examination or even a surgery
| | | | | |
Location-based upcoding: Billing for a procedure that occurred in an operating
| | | | | | | | | | |
room when, in fact, it had occurred in a less-expensive setting such as an office
| | | | | | | | | | | | | |
Time-based-upcoding: When a doctor sees a patient for 10-minutes, but bills for a | | | | | | | | | | | |
more expensive 45-minute consultation.
| | | |
Questions With Correct Answers
HCF Investigator Assumptions - CORRECT ANSWER✔✔-*General knowledge of
| | | | | | | |
the Health care Delivery System
| | | |
*Health plan policy and procedures relative to the delivery of services
| | | | | | | | | |
*Able to identify Red Flags, behaviors & indicators of health care fraud schemes
| | | | | | | | | | | |
Know applicable federal & state laws related to health care fraud
| | | | | | | | | |
*Law enforcement & regulatory agencies that have oversight responsibilities for
| | | | | | | | | |
HCF
*Local & regional investigative groups that have similar interests
| | | | | | | |
Fraud, by it's very nature, is decptive. - CORRECT ANSWER✔✔-As such, nobody
| | | | | | | | | | | |
really knows what the impact and cost of fraud is. However there are some
| | | | | | | | | | | | | |
common industry estimates | |
Conservative US Healthcare spending in 2015 was $3.2Trillion
| | | | | | |
,Conservative estimate of fraud is 3-5% (means tens of billions of dollars each
| | | | | | | | | | | | |
year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between 5% and
| | | | | | | | | | | | | | |
10%)
Anatomy of an investigation - CORRECT ANSWER✔✔-Each fraud case is unique,
| | | | | | | | | | |
however, under the surface of the specific schemes, all HCF investigatons have a
| | | | | | | | | | | | |
common structure, or process.
| | |
Anatomy of an investigation - 1) Detection - CORRECT ANSWER✔✔-The process
| | | | | | | | | | |
of uncovering potential fraud waste and abuse utilizing human and technical
| | | | | | | | | | |
resources and techniques
| |
Anatomy of an investigation - 2) Assessment - CORRECT ANSWER✔✔-The primary
| | | | | | | | | |
|objective of the assessment phase is to establish PREDICATION for the continued
| | | | | | | | | | | |
investigation
Predication - CORRECT ANSWER✔✔-to proclaim; declare; assert
| | | | | |
Anatomy of an Investigation - 3) Investigative Strategy - CORRECT ANSWER✔✔-
| | | | | | | | | |
Devoloping an investigative plan to identify and gather evidence to support the
| | | | | | | | | | | |
statuatory elements to prove
| | |
Anatomy of an investigation - 4) Case Investigation - CORRECT ANSWER✔✔-The
| | | | | | | | | | |
process of utilizing legal and appropriate techniques to prove or disprove the
| | | | | | | | | | | |
allegations
,Antomy of an investigation - 5) Report Writing - CORRECT ANSWER✔✔-The
| | | | | | | | | | |
process of documenting the investigative tasks in a final comprehensive
| | | | | | | | | |
investigative report. |
Anatomy of an investigation - 6) Determination of action - CORRECT ANSWER✔✔-
| | | | | | | | | | |
Evaluating the totality of the documented case facts to determine the best action
| | | | | | | | | | | | |
to resolve the investigation.
| | |
Anatomy of an investigation - 1) Detection - Case Management - CORRECT
| | | | | | | | | | | |
ANSWER✔✔-Includes:
*Behavioral & Pattern Analysis | | |
Emergings Schemes - being familiar enough with new schemes to be able to
| | | | | | | | | | | | |
recognize that something is "off"
| | | |
"Hot Spots": Know where the "hot-spots" are in the country
| | | | | | | | |
The top Red Flags for Health Care Fraud in 2018 - CORRECT ANSWER✔✔-1)
| | | | | | | | | | | | |
Opioids: 12 hotspots (Florida, Tennessee, Alaska, Texas); focus investigations and
| | | | | | | | | |
prosecuting "pill mills" (pharmacies that improperly divert and dispense Rx opioid
| | | | | | | | | |
and other opioid-related issues)
| | | |
2) Home Health Care:
| | | |
, 3) Use of data:
| | | |
4) Robosigning: Involves a doctor blindly writing Rx or order that authorize care
| | | | | | | | | | | | |
without first making an individualized determination of medical necessity.
| | | | | | | |
5) Kickbacks:
| |
6) Upcoding: The improper practice of a medical professional billing for a more
| | | | | | | | | | | | |
expensive medical service than was actually provided to the patient. The DOJ
| | | | | | | | | | | |
focuses on service-based, location-based or time-based upcoding
| | | | | |
7) Billing for unqualified workers:
| | | |
Upcoding - CORRECT ANSWER✔✔-The DOJ focuses on service-based, location-
| | | | | | | |
based and/or time-based upcoding
| | |
Service-based upcoding: A doctor may perform a simple check-up, but bill for a
| | | | | | | | | | | | |
more extensive examination or even a surgery
| | | | | |
Location-based upcoding: Billing for a procedure that occurred in an operating
| | | | | | | | | | |
room when, in fact, it had occurred in a less-expensive setting such as an office
| | | | | | | | | | | | | |
Time-based-upcoding: When a doctor sees a patient for 10-minutes, but bills for a | | | | | | | | | | | |
more expensive 45-minute consultation.
| | | |
