AHFI Accredited Health Care Fraud
Investigator Exam 2026 – Actual Questions &
Verified Solutions | Latest Updated Test Bank +
Certification Study Guide
AHFI ACCREDITED HEALTH CARE FRAUD INVESTIGATOR EXAM 2026
Actual Questions & Verified Solutions | Latest Updated Test Bank
Certification Study Guide — Questions
QUESTION 1
Which federal law is the PRIMARY statute used to prosecute health care fraud?
A. The False Claims Act (FCA)
B. The Anti-Kickback Statute (AKS)
C. The Health Insurance Portability and Accountability Act (HIPAA)
D. The Stark Law
E. The Racketeer Influenced and Corrupt Organizations Act (RICO)
CORRECT ANSWER: A. The False Claims Act (FCA)
RATIONALE: The False Claims Act (31 U.S.C. §§ 3729–3733) is the primary
federal statute used to prosecute health care fraud. It imposes civil liability on any
person or entity that knowingly submits false or fraudulent claims for payment to the
federal government, including Medicare and Medicaid. The FCA allows for treble
damages (three times the amount of the false claim) plus civil penalties per claim.
Importantly, it also contains the qui tam provisions that allow private citizens
(relators/whistleblowers) to file lawsuits on behalf of the government and receive a
portion of any recovery.
QUESTION 2
Under the False Claims Act, what is the term for a private individual who files a lawsuit
on behalf of the government?
A. Complainant
B. Informant
C. Relator
, D. Plaintiff
E. Whistleblower agent
CORRECT ANSWER: C. Relator
RATIONALE: Under the qui tam provisions of the False Claims Act, a private
individual who files a lawsuit on behalf of the government is called a "relator." The term
comes from the Latin phrase "ex relatione," meaning "upon relation of." The relator files
the suit under seal while the Department of Justice investigates, and if successful, the
relator is entitled to receive between 15% and 30% of the government's recovery,
depending on whether the government intervenes in the case.
QUESTION 3
Which of the following BEST defines "upcoding" in health care fraud?
A. Billing for services never rendered
B. Adding unnecessary procedures to a claim
C. Billing for a higher-level service than was actually provided
D. Submitting duplicate claims for the same service
E. Billing under a different provider's NPI number
CORRECT ANSWER: C. Billing for a higher-level service than was actually
provided
RATIONALE: Upcoding refers to the fraudulent practice of billing for a more
expensive or complex service than was actually performed. For example, billing a Level
5 Evaluation and Management (99215) visit when only a Level 2 (99212) service was
provided. Upcoding is one of the most prevalent forms of Medicare and Medicaid fraud
and is prosecutable under the False Claims Act. It directly increases reimbursement
beyond what is medically justified.
QUESTION 4
The Anti-Kickback Statute (AKS) prohibits which of the following?
A. Billing for services not covered by Medicare
B. Offering or receiving remuneration to induce or reward referrals of federally funded
health care services
, C. Providing false information on Medicare enrollment applications
D. Self-referral of designated health services
E. Failing to return overpayments within 60 days
CORRECT ANSWER: B. Offering or receiving remuneration to induce or
reward referrals of federally funded health care services
RATIONALE: The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) prohibits the
knowing and willful offer, payment, solicitation, or receipt of anything of value
("remuneration") to induce or reward patient referrals or the generation of business
involving any item or service covered by a federal health care program. Violations can
result in criminal fines, imprisonment, civil monetary penalties, and exclusion from
federal health care programs. The AKS applies to both payers and recipients.
QUESTION 5
What is the Stark Law primarily designed to prevent?
A. Fraudulent billing to Medicare for services not rendered
B. Physician self-referral to entities with which they have a financial relationship
C. Kickbacks from pharmaceutical companies to physicians
D. Identity theft of patient Medicare numbers
E. Billing Medicare under suspended provider numbers
CORRECT ANSWER: B. Physician self-referral to entities with which they have
a financial relationship
RATIONALE: The Stark Law (42 U.S.C. § 1395nn), also known as the Physician
Self-Referral Law, prohibits physicians from referring patients to receive "designated
health services" (DHS) payable by Medicare or Medicaid from entities with which the
physician or an immediate family member has a financial relationship, unless an
exception applies. Unlike the AKS, the Stark Law is a strict liability statute — meaning
no intent to violate the law is required. Violations result in denial of payment, refund
requirements, civil monetary penalties, and exclusion.
QUESTION 6
, Which government agency is PRIMARILY responsible for investigating Medicare and
Medicaid fraud?
A. The Department of Justice (DOJ)
B. The Federal Bureau of Investigation (FBI)
C. The Office of Inspector General (OIG) of HHS
D. The Centers for Medicare & Medicaid Services (CMS)
E. The Drug Enforcement Administration (DEA)
CORRECT ANSWER: C. The Office of Inspector General (OIG) of HHS
RATIONALE: The Office of Inspector General (OIG) of the U.S. Department of
Health and Human Services (HHS) is the primary federal agency responsible for
investigating Medicare and Medicaid fraud, waste, and abuse. The OIG conducts
audits, investigations, inspections, and evaluations to protect the integrity of HHS
programs. The OIG also has authority to exclude individuals and entities from
participation in federal health care programs and to impose civil monetary penalties
(CMPs).
QUESTION 7
"Phantom billing" in health care fraud refers to:
A. Billing for a service provided by an unlicensed provider
B. Submitting claims for services that were never actually provided
C. Billing for experimental procedures not covered by insurance
D. Charging patients more than what is billed to insurance
E. Using a deceased patient's insurance information to file claims
CORRECT ANSWER: B. Submitting claims for services that were never
actually provided
RATIONALE: Phantom billing (also called billing for services not rendered) is one of
the most straightforward and blatant forms of health care fraud. It involves submitting
claims to Medicare, Medicaid, or private insurers for medical services, procedures, or
supplies that were never actually provided to the patient. This practice directly defrauds
payers and is prosecutable under multiple statutes including the False Claims Act and
the federal health care fraud statute (18 U.S.C. § 1347).
Investigator Exam 2026 – Actual Questions &
Verified Solutions | Latest Updated Test Bank +
Certification Study Guide
AHFI ACCREDITED HEALTH CARE FRAUD INVESTIGATOR EXAM 2026
Actual Questions & Verified Solutions | Latest Updated Test Bank
Certification Study Guide — Questions
QUESTION 1
Which federal law is the PRIMARY statute used to prosecute health care fraud?
A. The False Claims Act (FCA)
B. The Anti-Kickback Statute (AKS)
C. The Health Insurance Portability and Accountability Act (HIPAA)
D. The Stark Law
E. The Racketeer Influenced and Corrupt Organizations Act (RICO)
CORRECT ANSWER: A. The False Claims Act (FCA)
RATIONALE: The False Claims Act (31 U.S.C. §§ 3729–3733) is the primary
federal statute used to prosecute health care fraud. It imposes civil liability on any
person or entity that knowingly submits false or fraudulent claims for payment to the
federal government, including Medicare and Medicaid. The FCA allows for treble
damages (three times the amount of the false claim) plus civil penalties per claim.
Importantly, it also contains the qui tam provisions that allow private citizens
(relators/whistleblowers) to file lawsuits on behalf of the government and receive a
portion of any recovery.
QUESTION 2
Under the False Claims Act, what is the term for a private individual who files a lawsuit
on behalf of the government?
A. Complainant
B. Informant
C. Relator
, D. Plaintiff
E. Whistleblower agent
CORRECT ANSWER: C. Relator
RATIONALE: Under the qui tam provisions of the False Claims Act, a private
individual who files a lawsuit on behalf of the government is called a "relator." The term
comes from the Latin phrase "ex relatione," meaning "upon relation of." The relator files
the suit under seal while the Department of Justice investigates, and if successful, the
relator is entitled to receive between 15% and 30% of the government's recovery,
depending on whether the government intervenes in the case.
QUESTION 3
Which of the following BEST defines "upcoding" in health care fraud?
A. Billing for services never rendered
B. Adding unnecessary procedures to a claim
C. Billing for a higher-level service than was actually provided
D. Submitting duplicate claims for the same service
E. Billing under a different provider's NPI number
CORRECT ANSWER: C. Billing for a higher-level service than was actually
provided
RATIONALE: Upcoding refers to the fraudulent practice of billing for a more
expensive or complex service than was actually performed. For example, billing a Level
5 Evaluation and Management (99215) visit when only a Level 2 (99212) service was
provided. Upcoding is one of the most prevalent forms of Medicare and Medicaid fraud
and is prosecutable under the False Claims Act. It directly increases reimbursement
beyond what is medically justified.
QUESTION 4
The Anti-Kickback Statute (AKS) prohibits which of the following?
A. Billing for services not covered by Medicare
B. Offering or receiving remuneration to induce or reward referrals of federally funded
health care services
, C. Providing false information on Medicare enrollment applications
D. Self-referral of designated health services
E. Failing to return overpayments within 60 days
CORRECT ANSWER: B. Offering or receiving remuneration to induce or
reward referrals of federally funded health care services
RATIONALE: The Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)) prohibits the
knowing and willful offer, payment, solicitation, or receipt of anything of value
("remuneration") to induce or reward patient referrals or the generation of business
involving any item or service covered by a federal health care program. Violations can
result in criminal fines, imprisonment, civil monetary penalties, and exclusion from
federal health care programs. The AKS applies to both payers and recipients.
QUESTION 5
What is the Stark Law primarily designed to prevent?
A. Fraudulent billing to Medicare for services not rendered
B. Physician self-referral to entities with which they have a financial relationship
C. Kickbacks from pharmaceutical companies to physicians
D. Identity theft of patient Medicare numbers
E. Billing Medicare under suspended provider numbers
CORRECT ANSWER: B. Physician self-referral to entities with which they have
a financial relationship
RATIONALE: The Stark Law (42 U.S.C. § 1395nn), also known as the Physician
Self-Referral Law, prohibits physicians from referring patients to receive "designated
health services" (DHS) payable by Medicare or Medicaid from entities with which the
physician or an immediate family member has a financial relationship, unless an
exception applies. Unlike the AKS, the Stark Law is a strict liability statute — meaning
no intent to violate the law is required. Violations result in denial of payment, refund
requirements, civil monetary penalties, and exclusion.
QUESTION 6
, Which government agency is PRIMARILY responsible for investigating Medicare and
Medicaid fraud?
A. The Department of Justice (DOJ)
B. The Federal Bureau of Investigation (FBI)
C. The Office of Inspector General (OIG) of HHS
D. The Centers for Medicare & Medicaid Services (CMS)
E. The Drug Enforcement Administration (DEA)
CORRECT ANSWER: C. The Office of Inspector General (OIG) of HHS
RATIONALE: The Office of Inspector General (OIG) of the U.S. Department of
Health and Human Services (HHS) is the primary federal agency responsible for
investigating Medicare and Medicaid fraud, waste, and abuse. The OIG conducts
audits, investigations, inspections, and evaluations to protect the integrity of HHS
programs. The OIG also has authority to exclude individuals and entities from
participation in federal health care programs and to impose civil monetary penalties
(CMPs).
QUESTION 7
"Phantom billing" in health care fraud refers to:
A. Billing for a service provided by an unlicensed provider
B. Submitting claims for services that were never actually provided
C. Billing for experimental procedures not covered by insurance
D. Charging patients more than what is billed to insurance
E. Using a deceased patient's insurance information to file claims
CORRECT ANSWER: B. Submitting claims for services that were never
actually provided
RATIONALE: Phantom billing (also called billing for services not rendered) is one of
the most straightforward and blatant forms of health care fraud. It involves submitting
claims to Medicare, Medicaid, or private insurers for medical services, procedures, or
supplies that were never actually provided to the patient. This practice directly defrauds
payers and is prosecutable under multiple statutes including the False Claims Act and
the federal health care fraud statute (18 U.S.C. § 1347).
