AHFI (ACCREDITED HEALTH CARE
FRAUD INVESTIGATOR) PRACTICE
EXAM COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, a ‘relator’ who brings a qui tam action may be entitled to what
percentage of the recovery if the government intervenes in the case?
A. 10% to 15%
B. 25% to 30%
C. 15% to 25%
D. 30% to 50%
Answer: C
Conceptual Explanation: If the government intervenes in a qui tam action under the False
Claims Act, the relator is generally entitled to receive between 15% and 25% of the
proceeds of the action or settlement.
2. Which coding practice involves using multiple CPT codes for parts of a procedure that
should be reported with a single comprehensive code?
A. Unbundling
,B. Cloning
C. Upcoding
D. Downcoding
Answer: A
Conceptual Explanation: Unbundling is the practice of billing multiple specific codes for
parts of a procedure instead of using a single comprehensive code that covers the entire
service.
3. The Stark Law (Physician Self-Referral Law) specifically prohibits physicians from referring
Medicare patients for ‘designated health services’ (DHS) to an entity if:
A. The physician receives any form of kickback for the referral.
B. The entity pays the physician for marketing services.
C. The physician has a financial relationship with the entity, unless an exception applies.
D. The patient has not consented to the referral in writing.
Answer: C
Conceptual Explanation: The Stark Law is a strict liability statute that prohibits
physicians from referring Medicare patients for DHS to entities with which the physician
(or immediate family) has a financial relationship, unless a specific exception is met.
, 4. In a medical audit, what does the ‘Modifier -25’ signify?
A. A significant, separately identifiable E/M service by the same physician on the same day
of a procedure.
B. A procedure was terminated early due to patient safety.
C. The service was provided by a physician assistant rather than a doctor.
D. Multiple procedures were performed during the same operative session.
Answer: A
Conceptual Explanation: Modifier -25 is used to report a significant, separately
identifiable evaluation and management (E/M) service by the same physician on the same
day of a procedure or other health care service.
5. Which of the following best describes ‘Phantom Billing’?
A. Billing for a more expensive service than what was performed.
B. Billing the same service to two different insurance companies.
C. Billing for services provided by an unlicensed provider.
D. Billing for services that were never actually provided to the patient.
Answer: D
Conceptual Explanation: Phantom billing is a form of healthcare fraud where a provider
bills for tests, procedures, or supplies that were never administered or delivered.
FRAUD INVESTIGATOR) PRACTICE
EXAM COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, a ‘relator’ who brings a qui tam action may be entitled to what
percentage of the recovery if the government intervenes in the case?
A. 10% to 15%
B. 25% to 30%
C. 15% to 25%
D. 30% to 50%
Answer: C
Conceptual Explanation: If the government intervenes in a qui tam action under the False
Claims Act, the relator is generally entitled to receive between 15% and 25% of the
proceeds of the action or settlement.
2. Which coding practice involves using multiple CPT codes for parts of a procedure that
should be reported with a single comprehensive code?
A. Unbundling
,B. Cloning
C. Upcoding
D. Downcoding
Answer: A
Conceptual Explanation: Unbundling is the practice of billing multiple specific codes for
parts of a procedure instead of using a single comprehensive code that covers the entire
service.
3. The Stark Law (Physician Self-Referral Law) specifically prohibits physicians from referring
Medicare patients for ‘designated health services’ (DHS) to an entity if:
A. The physician receives any form of kickback for the referral.
B. The entity pays the physician for marketing services.
C. The physician has a financial relationship with the entity, unless an exception applies.
D. The patient has not consented to the referral in writing.
Answer: C
Conceptual Explanation: The Stark Law is a strict liability statute that prohibits
physicians from referring Medicare patients for DHS to entities with which the physician
(or immediate family) has a financial relationship, unless a specific exception is met.
, 4. In a medical audit, what does the ‘Modifier -25’ signify?
A. A significant, separately identifiable E/M service by the same physician on the same day
of a procedure.
B. A procedure was terminated early due to patient safety.
C. The service was provided by a physician assistant rather than a doctor.
D. Multiple procedures were performed during the same operative session.
Answer: A
Conceptual Explanation: Modifier -25 is used to report a significant, separately
identifiable evaluation and management (E/M) service by the same physician on the same
day of a procedure or other health care service.
5. Which of the following best describes ‘Phantom Billing’?
A. Billing for a more expensive service than what was performed.
B. Billing the same service to two different insurance companies.
C. Billing for services provided by an unlicensed provider.
D. Billing for services that were never actually provided to the patient.
Answer: D
Conceptual Explanation: Phantom billing is a form of healthcare fraud where a provider
bills for tests, procedures, or supplies that were never administered or delivered.
