AHFI (ACCREDITED HEALTH CARE
FRAUD INVESTIGATOR) FINAL EXAM
2026/2027 COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, what is the standard for ‘knowledge’ regarding the submission
of a false claim?
A. Specific intent to defraud the government must be proven
B. Actual knowledge, deliberate ignorance, or reckless disregard
C. Actual knowledge only
D. Gross negligence without the requirement of intent
Answer: B
Conceptual Explanation: The False Claims Act (FCA) defines ‘knowing’ to include actual
knowledge, deliberate ignorance of the truth or falsity of the information, or reckless
disregard. It specifically states that no proof of specific intent to defraud is required.
2. A provider bills for a comprehensive metabolic panel and also bills separately for each
individual component of the test. This practice is known as:
A. Upcoding
,B. Balance billing
C. Phantom billing
D. Unbundling
Answer: D
Conceptual Explanation: Unbundling (also known as fragmenting) is the practice of
billing multiple CPT codes for individual parts of a procedure when a single comprehensive
code exists that covers all components, usually to increase reimbursement.
3. Which federal statute prohibits the offering, paying, soliciting, or receiving of remuneration
to induce referrals for items or services reimbursed by federal health care programs?
A. Anti-Kickback Statute (AKS)
B. HIPAA Privacy Rule
C. Stark Law
D. Civil Monetary Penalties Law
Answer: A
Conceptual Explanation: The Anti-Kickback Statute (AKS) is a criminal law that prohibits
the exchange of anything of value (remuneration) in return for federal health care program
business referrals.
, 4. What is the primary difference between the Anti-Kickback Statute (AKS) and the Stark
Law?
A. AKS is a civil law, while Stark Law is a criminal law
B. AKS requires no proof of intent, whereas Stark Law requires proof of willful intent
C. Stark Law applies only to physicians and designated health services, while AKS is
broader
D. Stark Law applies to all payers, including private insurance
Answer: C
Conceptual Explanation: Stark Law is a strict liability civil statute that specifically targets
physician self-referrals for ‘Designated Health Services’ (DHS). AKS is a criminal statute
that applies to any source of referral and requires proof of intent.
5. An investigator notices that a physician consistently bills for CPT code 99215 (Level 5 Office
Visit) for every patient, regardless of the severity of the illness. This is an example of:
A. Undercoding
B. Unbundling
C. Upcoding
D. Medical necessity
Answer: C
FRAUD INVESTIGATOR) FINAL EXAM
2026/2027 COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, what is the standard for ‘knowledge’ regarding the submission
of a false claim?
A. Specific intent to defraud the government must be proven
B. Actual knowledge, deliberate ignorance, or reckless disregard
C. Actual knowledge only
D. Gross negligence without the requirement of intent
Answer: B
Conceptual Explanation: The False Claims Act (FCA) defines ‘knowing’ to include actual
knowledge, deliberate ignorance of the truth or falsity of the information, or reckless
disregard. It specifically states that no proof of specific intent to defraud is required.
2. A provider bills for a comprehensive metabolic panel and also bills separately for each
individual component of the test. This practice is known as:
A. Upcoding
,B. Balance billing
C. Phantom billing
D. Unbundling
Answer: D
Conceptual Explanation: Unbundling (also known as fragmenting) is the practice of
billing multiple CPT codes for individual parts of a procedure when a single comprehensive
code exists that covers all components, usually to increase reimbursement.
3. Which federal statute prohibits the offering, paying, soliciting, or receiving of remuneration
to induce referrals for items or services reimbursed by federal health care programs?
A. Anti-Kickback Statute (AKS)
B. HIPAA Privacy Rule
C. Stark Law
D. Civil Monetary Penalties Law
Answer: A
Conceptual Explanation: The Anti-Kickback Statute (AKS) is a criminal law that prohibits
the exchange of anything of value (remuneration) in return for federal health care program
business referrals.
, 4. What is the primary difference between the Anti-Kickback Statute (AKS) and the Stark
Law?
A. AKS is a civil law, while Stark Law is a criminal law
B. AKS requires no proof of intent, whereas Stark Law requires proof of willful intent
C. Stark Law applies only to physicians and designated health services, while AKS is
broader
D. Stark Law applies to all payers, including private insurance
Answer: C
Conceptual Explanation: Stark Law is a strict liability civil statute that specifically targets
physician self-referrals for ‘Designated Health Services’ (DHS). AKS is a criminal statute
that applies to any source of referral and requires proof of intent.
5. An investigator notices that a physician consistently bills for CPT code 99215 (Level 5 Office
Visit) for every patient, regardless of the severity of the illness. This is an example of:
A. Undercoding
B. Unbundling
C. Upcoding
D. Medical necessity
Answer: C
