AHFI EXAM 168 2026 BILLING AND CODING
INVESTIGATION WORKBOOK SOLVED
QUESTIONS COMPILATION
◉ Billing for unqualified workers.
Answer: Unqualified or unlicensed workers.
Clinics using a less qualified worker (such as a P.A.) to render
services to a patient, but the services are billed as if they were
provided by a medical professional with a higher reimbursement
rate.
Or billing of lower-level medical professionals (physical therapy
assistants) who are supposed to be supervised by a higher-level
medical professional (a physical therapist) but operate without
supervision
◉ Kickbacks.
Answer: The payment of kickbacks or other illicit benefits to
patients, recruiters who procure such patients, or even to doctors or
other medical professionals..
,Look for patients who are "frequent-flyers", or who present with a
number of different ailments over time that seem implausible
◉ Use of data in uncovering fraud.
Answer: Identifying geographic hotbeds for fraud (top biller in the
country for a specific code is not a good thing);
looking for a disconnect between the size of the medical practice and
the volume of billing;
inconguity between the practice's specialty and the types of codes
billed;
Rx for high % of opioids
◉ Home Health Fraud.
Answer: Hot-spots: South Forida, Detroit, TX, IL)
Prescribed by a doctor when the patient is homebound and needs
intermittent skilled care.
Watch for MDs who write Rx for home health care when there is no
real medical necessity;
,Unlicensed workers rendering care;
Billing for services not rendered (no-show workers), and
Kickbacks being paid to recruit patients.
◉ The 5 characteristrics associated with home health fraud are.
Answer: 1) A high % of episodes in which the patient is NOT visited
by the supervising physician
2) A high % of episodes that didn't follow a hosptial or nursing home
stay.
3) A high % of episodes with a primary diagnosis of diabetes or
hypertension
4) A high % of claims for multiple HHA for 1 patient
5) A high % of patients with multiple home health readmission in a
short time frame.
◉ Detection - Cross Functional Departments.
, Answer: Each department of the insurer has an opportunity to flag a
member or provider
The payer
Sales
Claims
Provider Relations
Legal
◉ Detection _Hotlines.
Answer: Patients, providers and employees
◉ Detection - NHCAA.
Answer: RIA - Request for Investigative Assistance
SIRIS - Fraud prevention by LexisNexis Risk Solutions and NHCAA.
SIRIS is a contributory database that allows NHCAA members to
submit, track, monitor and share information related to potential
provider fraud and associated investigations. Incorporates public
INVESTIGATION WORKBOOK SOLVED
QUESTIONS COMPILATION
◉ Billing for unqualified workers.
Answer: Unqualified or unlicensed workers.
Clinics using a less qualified worker (such as a P.A.) to render
services to a patient, but the services are billed as if they were
provided by a medical professional with a higher reimbursement
rate.
Or billing of lower-level medical professionals (physical therapy
assistants) who are supposed to be supervised by a higher-level
medical professional (a physical therapist) but operate without
supervision
◉ Kickbacks.
Answer: The payment of kickbacks or other illicit benefits to
patients, recruiters who procure such patients, or even to doctors or
other medical professionals..
,Look for patients who are "frequent-flyers", or who present with a
number of different ailments over time that seem implausible
◉ Use of data in uncovering fraud.
Answer: Identifying geographic hotbeds for fraud (top biller in the
country for a specific code is not a good thing);
looking for a disconnect between the size of the medical practice and
the volume of billing;
inconguity between the practice's specialty and the types of codes
billed;
Rx for high % of opioids
◉ Home Health Fraud.
Answer: Hot-spots: South Forida, Detroit, TX, IL)
Prescribed by a doctor when the patient is homebound and needs
intermittent skilled care.
Watch for MDs who write Rx for home health care when there is no
real medical necessity;
,Unlicensed workers rendering care;
Billing for services not rendered (no-show workers), and
Kickbacks being paid to recruit patients.
◉ The 5 characteristrics associated with home health fraud are.
Answer: 1) A high % of episodes in which the patient is NOT visited
by the supervising physician
2) A high % of episodes that didn't follow a hosptial or nursing home
stay.
3) A high % of episodes with a primary diagnosis of diabetes or
hypertension
4) A high % of claims for multiple HHA for 1 patient
5) A high % of patients with multiple home health readmission in a
short time frame.
◉ Detection - Cross Functional Departments.
, Answer: Each department of the insurer has an opportunity to flag a
member or provider
The payer
Sales
Claims
Provider Relations
Legal
◉ Detection _Hotlines.
Answer: Patients, providers and employees
◉ Detection - NHCAA.
Answer: RIA - Request for Investigative Assistance
SIRIS - Fraud prevention by LexisNexis Risk Solutions and NHCAA.
SIRIS is a contributory database that allows NHCAA members to
submit, track, monitor and share information related to potential
provider fraud and associated investigations. Incorporates public
