AHFI (Accredited Health Care Fraud Investigator)
Examination – ACTUAL EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS LATEST
UPDATE
,*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. - 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
HCF Investigator Assumptions - *General knowledge of the Health care Delivery
System
*Health plan policy and procedures relative to the delivery of services
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 - 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 - The process of uncovering potential fraud
waste and abuse utilizing human and technical resources and techniques
Anatomy of an investigation - 2) Assessment - The primary objective of the assessment
phase is to establish PREDICATION for the continued investigation
Predication - to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Devoloping an investigative
plan to identify and gather evidence to support the statuatory elements to prove
Anatomy of an investigation - 4) Case Investigation - The process of utilizing legal and
appropriate techniques to prove or disprove the allegations
, Antomy of an investigation - 5) Report Writing - The process of documenting the
investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - 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 - 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 - 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 - 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.
Examination – ACTUAL EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS LATEST
UPDATE
,*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. - 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
HCF Investigator Assumptions - *General knowledge of the Health care Delivery
System
*Health plan policy and procedures relative to the delivery of services
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 - 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 - The process of uncovering potential fraud
waste and abuse utilizing human and technical resources and techniques
Anatomy of an investigation - 2) Assessment - The primary objective of the assessment
phase is to establish PREDICATION for the continued investigation
Predication - to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Devoloping an investigative
plan to identify and gather evidence to support the statuatory elements to prove
Anatomy of an investigation - 4) Case Investigation - The process of utilizing legal and
appropriate techniques to prove or disprove the allegations
, Antomy of an investigation - 5) Report Writing - The process of documenting the
investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - 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 - 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 - 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 - 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.
