AHFI EXAMINATION PREP COURSE EXAM 2026/27 QUESTIONS AND
ANSWERS ASSURED SUCCESS
Penalties include
Fines $15,000/violation
Exclusion from participation in the Federal health care programs
Exclusion Statute (42 U.S.C. SS 1320a-7)
OIG is legally required to exclude from participation in all Federal
health care programs individuals and entities convicted of the
following types of criminal offenses
* Medicare or Medicaid fraud
* Patient neglect or abuse
* Felony convictions for other health-care-related fraud, theft, or
other financial misconduct
* Felony convictions for unlawful manufacture, distribution,
prescription, or dispensing of controlled substances.
OIG has DISCRETION to exclude individuals and entities on serveral
other grounds, including misdemeanor convictions related to health
care fraud other than Medicare or Medicaid fraudc (commercial
plans) or misdemeanor convictions in connection with the unlawful
manufacture, distribution, prescription or dispensing of controlled
substances, suspension, revocation or surrender of a license to
provide health care for reasons bearing on professional competence,
,profressional performance, or financial integrity, or defaulting on
health education loan or scholarship obligatioins.
Conservative US Healthcare spending in 2015 was
$3.2T
Conservative estimate of fraud is 3%-5%
Tens of billions of dollars each year.
$96Billion (3%) to $320 Billion (10%)
Each fraud case is unique, but under the surface of the specific
schemes,
All HCF investigations have a common structure or process
The 6 stages of an investigation
Detection
Assessment
Investigative Strategy
Case investigation
Report Writing
Determination of action
,Case investigation
The process of utilizing legal and appropriate techniques to prove or
disprove the allegations
Determination of action
Evaluating the totality of the documented case facts to determine
the best action to resolve the investigation
Report writing
The process of documenting the investigative tasks in a final
comprehensive investigative report
Investigative strategy
Developing an investigative plan to identify and gather evidence to
support the statutory elements to prove
Assessment
The primary objective of the assessment phase is to establish
"predication" for the continued investigation
, Detection
The process of uncovering potential fraud, waste and abuse utilizing
human and technical resources and techniques
Detection- includes the following
Case Management System (Behavioral and Pattern Analysis;
Emerging Schemes, Hot Spots of fraud activity)
Cross functional Departments
LE: Intelligence, Vice, OC
Payer: Sales, Claims, Provider Relations, Legal
Hotline (Patients, providers, employees)
NHCAA (RIA and SIRIS)
Information Sharing (SIU, Anti-Fraud Organizations, and Task Forces)
Media (Knock-Knock)
What is SIRIS?
A database of providers under investigation by NHCAA member
organizations
ANSWERS ASSURED SUCCESS
Penalties include
Fines $15,000/violation
Exclusion from participation in the Federal health care programs
Exclusion Statute (42 U.S.C. SS 1320a-7)
OIG is legally required to exclude from participation in all Federal
health care programs individuals and entities convicted of the
following types of criminal offenses
* Medicare or Medicaid fraud
* Patient neglect or abuse
* Felony convictions for other health-care-related fraud, theft, or
other financial misconduct
* Felony convictions for unlawful manufacture, distribution,
prescription, or dispensing of controlled substances.
OIG has DISCRETION to exclude individuals and entities on serveral
other grounds, including misdemeanor convictions related to health
care fraud other than Medicare or Medicaid fraudc (commercial
plans) or misdemeanor convictions in connection with the unlawful
manufacture, distribution, prescription or dispensing of controlled
substances, suspension, revocation or surrender of a license to
provide health care for reasons bearing on professional competence,
,profressional performance, or financial integrity, or defaulting on
health education loan or scholarship obligatioins.
Conservative US Healthcare spending in 2015 was
$3.2T
Conservative estimate of fraud is 3%-5%
Tens of billions of dollars each year.
$96Billion (3%) to $320 Billion (10%)
Each fraud case is unique, but under the surface of the specific
schemes,
All HCF investigations have a common structure or process
The 6 stages of an investigation
Detection
Assessment
Investigative Strategy
Case investigation
Report Writing
Determination of action
,Case investigation
The process of utilizing legal and appropriate techniques to prove or
disprove the allegations
Determination of action
Evaluating the totality of the documented case facts to determine
the best action to resolve the investigation
Report writing
The process of documenting the investigative tasks in a final
comprehensive investigative report
Investigative strategy
Developing an investigative plan to identify and gather evidence to
support the statutory elements to prove
Assessment
The primary objective of the assessment phase is to establish
"predication" for the continued investigation
, Detection
The process of uncovering potential fraud, waste and abuse utilizing
human and technical resources and techniques
Detection- includes the following
Case Management System (Behavioral and Pattern Analysis;
Emerging Schemes, Hot Spots of fraud activity)
Cross functional Departments
LE: Intelligence, Vice, OC
Payer: Sales, Claims, Provider Relations, Legal
Hotline (Patients, providers, employees)
NHCAA (RIA and SIRIS)
Information Sharing (SIU, Anti-Fraud Organizations, and Task Forces)
Media (Knock-Knock)
What is SIRIS?
A database of providers under investigation by NHCAA member
organizations
