AHFI Examination Prep Course Exam 2026/2027 Questions And Answers | Graded A+

AHFI Examination Prep Course Exam 2026/2027 Questions And Answers | Graded A+ HCF Investigator Assumptions - answer-*General knowledge of the Health care Delivery System *Health plan policy and procedures relative to the delivery of services *Able to identify Red Flags, behaviors & indicators of health care fraud schemes Know applicable federal & state laws related to health care fraud *Law enforcement & regulatory agencies that have oversight responsibilities for HCF *Local & regional investigative groups that have similar interests Fraud, by it's very nature, is decptive. - answer-As such, nobody really knows what the impact and cost of fraud is. However there are some common industry estimates Conservative US Healthcare spending in 2015 was $3.2Trillion Conservative estimate of fraud is 3-5% (means tens of billions of dollars each year) Estimate of $96 billion - $320 Billion / year (if we estimate between 5% and 10%)Anatomy of an investigation - answer-Each fraud case is unique, however, under the surface of the specific schemes, all HCF investigatons have a common structure, or process. Anatomy of an investigation - 1) Detection - answer-The process of uncovering potential fraud waste and abuse utilizing human and technical resources and techniques Anatomy of an investigation - 2) Assessment - answer-The primary objective of the assessment phase is to establish PREDICATION for the continued investigation Predication - answer-to proclaim; declare; assert Anatomy of an Investigation - 3) Investigative Strategy - answer-Devoloping an investigative plan to identify and gather evidence to support the statuatory elements to prove Anatomy of an investigation - 4) Case Investigation - answer-The process of utilizing legal and appropriate techniques to prove or disprove the allegations Antomy of an investigation - 5) Report Writing - answer-The process of documenting the investigative tasks in a final comprehensive investigative report. Anatomy of an investigation - 6) Determination of action - answer-Evaluating the totality of the documented case facts to determine the best action to resolve the investigation. Anatomy of an investigation - 1) Detection - Case Management - answer-Includes: *Behavioral & Pattern AnalysisEmergings 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 The top Red Flags for Health Care Fraud in 2018 - answer-1) Opioids: 12 hotspots (Florida, Tennessee, Alaska, Texas); focus investigations and prosecuting "pill mills" (pharmacies that improperly divert and dispense Rx opioid and other opioid-related issues) 2) Home Health Care: 3) Use of data: 4) Robosigning: Involves a doctor blindly writing Rx or order that authorize care without first making an individualized determination of medical necessity. 5) Kickbacks: 6) Upcoding: The improper practice of a medical professional billing for a more expensive medical service than was actually provided to the patient. The DOJ focuses on service-based, location-based or time-based upcoding 7) Billing for unqualified workers: Upcoding - answer-The DOJ focuses on service-based, location-based and/or time-based upcodingService-based upcoding: A doctor may perform a simple check-up, but bill for a more extensive examination or even a surgery Location-based upcoding: Billing for a procedure that occurred in an operating room when, in fact, it had occurred in a less-expensive setting such as an office Time-based-upcoding: When a doctor sees a patient for 10-minutes, but bills for a more expensive 45-minute consultation. Robosigning - answer-Involves a doctor blindly writing Rx or order that authorize care without first making an individualized determination of medical necessity. (Opioids; home health care; power wheelchairs; sleep studies) **The authorizing medical professional must make a case-bycase analysis of medical necessity before ordering drugs or services. And importantly, the company should be able to re-create and affirmatively prove this process was actually used Billing for unqualified workers - answer-Unqualified or unlicensed workers. Clinics using a less qualified worker (such as a P.A.) to render services to a patient, but the services are billed as if they were provided by a medical professional with a higher reimbursement rate. Or billing of lower-level medical professionals (physical therapy assistants) who are supposed to be supervised by a higher-level medical professional (a physical therapist) but operate without supervision Kickbacks - answer-The payment of kickbacks or other illicit benefits to patients, recruiters who procure such patients, or even to doctors or other medical professionals.. Look for patients who are "frequent-flyers", or who present with a number of different ailments over time that seem implausibleUse of data in uncovering fraud - answer-Identifying geographic hotbeds for fraud (top biller in the country for a specific code is not a good thing