AHFI EXAM ADVANCED STUDY GUIDE
COMPLETE QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE
1. Under the False Claims Act (FCA), what is the specific knowledge requirement for liability?
A. Proof of specific intent to defraud the government
B. Actual knowledge, deliberate ignorance, or reckless disregard of the truth
C. Negligence in the preparation of medical claims
D. Knowledge is not required; it is a strict liability statute
Answer: B
Conceptual Explanation: The FCA does not require proof of specific intent to defraud.
Liability is established if the person has actual knowledge, acts in deliberate ignorance, or
acts in reckless disregard of the truth or falsity of the information.
2. Which legal doctrine allows a private individual to file a lawsuit on behalf of the
government to recover losses from fraud?
A. Qui tam
B. Stare decisis
C. Res ipsa loquitur
D. Habeas corpus
,Answer: A
Conceptual Explanation: Qui tam provisions in the False Claims Act allow whistleblowers
(relators) to sue on behalf of the government and share in the recovered proceeds.
3. The Stark Law primarily differs from the Anti-Kickback Statute (AKS) in that:
A. Stark is a criminal statute, while AKS is civil
B. Stark only applies to Medicare/Medicaid, while AKS applies to all commercial payers
C. Stark is a strict liability statute with no intent requirement, whereas AKS requires intent
D. AKS only prohibits cash payments, while Stark prohibits any form of remuneration
Answer: C
Conceptual Explanation: Stark Law is a strict liability statute, meaning no intent to violate
the law is required. The AKS is a criminal and civil statute that requires ‘knowing and
willful’ intent.
4. What is the primary purpose of CPT Modifier 25?
A. To identify a significant, separately identifiable E/M service by the same physician on
the same day of a procedure
B. To indicate a bilateral procedure
C. To signal that a procedure was discontinued due to patient safety concerns
D. To indicate that the service was performed by a physician assistant rather than a doctor
Answer: A
, Conceptual Explanation: Modifier 25 is used when a provider performs a separate
Evaluation and Management service on the same day as a minor procedure or other
service.
5. Which of the following describes ‘unbundling’ in medical billing?
A. Reporting multiple codes for parts of a procedure that should be captured by a single
comprehensive code
B. Submitting multiple bills for a single patient on different days
C. Billing for a higher level of service than was actually provided
D. Billing for services provided by an unlicensed assistant under the provider’s NPI
Answer: A
Conceptual Explanation: Unbundling is the practice of billing separately for components
of a procedure that are included in a single global code, often to increase reimbursement.
6. In the context of healthcare fraud data mining, what does ‘Benford’s Law’ primarily help
investigators identify?
A. The geographic density of fraudulent providers
B. The likelihood of a patient filing a whistleblower lawsuit
C. Anomalous frequency distributions of digits in numerical data sets
D. The time delay between service delivery and claim submission
Answer: C
COMPLETE QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE
1. Under the False Claims Act (FCA), what is the specific knowledge requirement for liability?
A. Proof of specific intent to defraud the government
B. Actual knowledge, deliberate ignorance, or reckless disregard of the truth
C. Negligence in the preparation of medical claims
D. Knowledge is not required; it is a strict liability statute
Answer: B
Conceptual Explanation: The FCA does not require proof of specific intent to defraud.
Liability is established if the person has actual knowledge, acts in deliberate ignorance, or
acts in reckless disregard of the truth or falsity of the information.
2. Which legal doctrine allows a private individual to file a lawsuit on behalf of the
government to recover losses from fraud?
A. Qui tam
B. Stare decisis
C. Res ipsa loquitur
D. Habeas corpus
,Answer: A
Conceptual Explanation: Qui tam provisions in the False Claims Act allow whistleblowers
(relators) to sue on behalf of the government and share in the recovered proceeds.
3. The Stark Law primarily differs from the Anti-Kickback Statute (AKS) in that:
A. Stark is a criminal statute, while AKS is civil
B. Stark only applies to Medicare/Medicaid, while AKS applies to all commercial payers
C. Stark is a strict liability statute with no intent requirement, whereas AKS requires intent
D. AKS only prohibits cash payments, while Stark prohibits any form of remuneration
Answer: C
Conceptual Explanation: Stark Law is a strict liability statute, meaning no intent to violate
the law is required. The AKS is a criminal and civil statute that requires ‘knowing and
willful’ intent.
4. What is the primary purpose of CPT Modifier 25?
A. To identify a significant, separately identifiable E/M service by the same physician on
the same day of a procedure
B. To indicate a bilateral procedure
C. To signal that a procedure was discontinued due to patient safety concerns
D. To indicate that the service was performed by a physician assistant rather than a doctor
Answer: A
, Conceptual Explanation: Modifier 25 is used when a provider performs a separate
Evaluation and Management service on the same day as a minor procedure or other
service.
5. Which of the following describes ‘unbundling’ in medical billing?
A. Reporting multiple codes for parts of a procedure that should be captured by a single
comprehensive code
B. Submitting multiple bills for a single patient on different days
C. Billing for a higher level of service than was actually provided
D. Billing for services provided by an unlicensed assistant under the provider’s NPI
Answer: A
Conceptual Explanation: Unbundling is the practice of billing separately for components
of a procedure that are included in a single global code, often to increase reimbursement.
6. In the context of healthcare fraud data mining, what does ‘Benford’s Law’ primarily help
investigators identify?
A. The geographic density of fraudulent providers
B. The likelihood of a patient filing a whistleblower lawsuit
C. Anomalous frequency distributions of digits in numerical data sets
D. The time delay between service delivery and claim submission
Answer: C
