1|Page
AHFI EXAMINATION PREP COURSE QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS
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
,2|Page
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
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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.
, 4|Page
Anatomy of an investigation - 1) Detection - Case Management -
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
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:
AHFI EXAMINATION PREP COURSE QUESTIONS AND
ANSWERS WITH COMPLETE SOLUTIONS
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
,2|Page
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
,3|Page
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.
, 4|Page
Anatomy of an investigation - 1) Detection - Case Management -
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
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:
