AHFI Examination Prep Course Fraud Detection
and Investigation EXAM SOLVED QUESTIONS WITH
ANSWERS.
- CORRECT ANSWER✅✅
- CORRECT ANSWER✅✅
- CORRECT ANSWER✅✅
5 most important Federal fraud and abuse laws that apply to physicians - CORRECT
ANSWER✅✅False Claims Act (FCA)
The Anti-Kickback Statute (AKS)
The Physician Self-Referral Law (Stark Law)
The Exclusion Authorities
Civil Monetary Penalties Law (CMPL)
**Government agencies including"
Department of Justice
Department of Health & Human Services Office of Inspector General (OIG)
Centers for Medicare & Medicaid Services (CMS)
These 3 are charged with enforcing the above 5 laws.
A Pivot table is a good tool to - CORRECT ANSWER✅✅Summarize Data
A SVRS is used to - CORRECT ANSWER✅✅select a sample of items that can later be
extrapolated
Adverse Benefit Determiniatioin under ERISA - CORRECT ANSWER✅✅* Defined as a
denial, reduction, or termination of payment under a benefit plan
* Includes instances where partial payment is made
* Participant in an ERISA plan has a right to a full and fair review of any adverse benefit
determination
AKS - CORRECT ANSWER✅✅Anti-Kickback Statute
,Criminal Statute which prohibits the knowing and willful payment of remuneration in
exchange (or offer of exchange) of anything of value in an effort to induce (or reward)
the referral of federal health care program business (42 U.S.C SS 1320a-7b)
Remuneration includes ANYTHING of value
**In some industries, it is acceptable to reward those who refer business to you.
However, in the Federal Health Care programs, paying for referrals is a crime.
Each party's intent is a key element of their liability under the AKS
Criminal penalties and administrative sanctions for violating the AKS include
Fines
Jail terms
Exclusion from participation in the Federal health care programs.
Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to
$50,000 per kickback + 3x the amount of the remuneration.
Kickbacks in health care can lead to
Overutilization
Increased program costs
Corruption of medical decision making
Patient steering
Unfair competition
**Routinely waiving copayment could implicate the AKS and you may not advertize that
you will forgive copays. However, you are free to waive a copay if you make an
individual determination that the patient cannot afford to pay or if your reasonable
collection efforts fail. It is also legal to provide free of discounted services to uninsured
people.
An investigative Plan - CORRECT ANSWER✅✅* Assists SIU management in
determining if the investigator is on the right track
* Ensure efficient use of resources
* Eliminates duplication of efforts
* Keeps the investigation organized (if the assigned investigator changes)
* Offers a template for new investigators
* Aids in drafting the final memorandum of investigation (MOI)
Onsite inspections should be treated similarly
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
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
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
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 - CORRECT ANSWER✅✅Each fraud case is unique,
however, under the surface of the specific schemes, all HCF investigatons have a
common structure, or process.
Antomy of an investigation - 5) Report Writing - CORRECT ANSWER✅✅The process
of documenting the investigative tasks in a final comprehensive investigative report.
Assessment - CORRECT ANSWER✅✅The primary objective of the assessment phase
is to establish "predication" for the continued investigation
Assessment: - CORRECT ANSWER✅✅The primary objective of assessment is to
establish PREDICATION for continued investigation
Backbround checks can be conducted using a variety of resources - CORRECT
ANSWER✅✅Internal resources
Public sources
3rd party data
Restricted access data
and Investigation EXAM SOLVED QUESTIONS WITH
ANSWERS.
- CORRECT ANSWER✅✅
- CORRECT ANSWER✅✅
- CORRECT ANSWER✅✅
5 most important Federal fraud and abuse laws that apply to physicians - CORRECT
ANSWER✅✅False Claims Act (FCA)
The Anti-Kickback Statute (AKS)
The Physician Self-Referral Law (Stark Law)
The Exclusion Authorities
Civil Monetary Penalties Law (CMPL)
**Government agencies including"
Department of Justice
Department of Health & Human Services Office of Inspector General (OIG)
Centers for Medicare & Medicaid Services (CMS)
These 3 are charged with enforcing the above 5 laws.
A Pivot table is a good tool to - CORRECT ANSWER✅✅Summarize Data
A SVRS is used to - CORRECT ANSWER✅✅select a sample of items that can later be
extrapolated
Adverse Benefit Determiniatioin under ERISA - CORRECT ANSWER✅✅* Defined as a
denial, reduction, or termination of payment under a benefit plan
* Includes instances where partial payment is made
* Participant in an ERISA plan has a right to a full and fair review of any adverse benefit
determination
AKS - CORRECT ANSWER✅✅Anti-Kickback Statute
,Criminal Statute which prohibits the knowing and willful payment of remuneration in
exchange (or offer of exchange) of anything of value in an effort to induce (or reward)
the referral of federal health care program business (42 U.S.C SS 1320a-7b)
Remuneration includes ANYTHING of value
**In some industries, it is acceptable to reward those who refer business to you.
However, in the Federal Health Care programs, paying for referrals is a crime.
Each party's intent is a key element of their liability under the AKS
Criminal penalties and administrative sanctions for violating the AKS include
Fines
Jail terms
Exclusion from participation in the Federal health care programs.
Under the CMPL, physicians who pay or accept kickbacks also face penalties of up to
$50,000 per kickback + 3x the amount of the remuneration.
Kickbacks in health care can lead to
Overutilization
Increased program costs
Corruption of medical decision making
Patient steering
Unfair competition
**Routinely waiving copayment could implicate the AKS and you may not advertize that
you will forgive copays. However, you are free to waive a copay if you make an
individual determination that the patient cannot afford to pay or if your reasonable
collection efforts fail. It is also legal to provide free of discounted services to uninsured
people.
An investigative Plan - CORRECT ANSWER✅✅* Assists SIU management in
determining if the investigator is on the right track
* Ensure efficient use of resources
* Eliminates duplication of efforts
* Keeps the investigation organized (if the assigned investigator changes)
* Offers a template for new investigators
* Aids in drafting the final memorandum of investigation (MOI)
Onsite inspections should be treated similarly
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
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
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
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 - CORRECT ANSWER✅✅Each fraud case is unique,
however, under the surface of the specific schemes, all HCF investigatons have a
common structure, or process.
Antomy of an investigation - 5) Report Writing - CORRECT ANSWER✅✅The process
of documenting the investigative tasks in a final comprehensive investigative report.
Assessment - CORRECT ANSWER✅✅The primary objective of the assessment phase
is to establish "predication" for the continued investigation
Assessment: - CORRECT ANSWER✅✅The primary objective of assessment is to
establish PREDICATION for continued investigation
Backbround checks can be conducted using a variety of resources - CORRECT
ANSWER✅✅Internal resources
Public sources
3rd party data
Restricted access data
