AHFI EXAM 168 2026 COMPLIANCE AND
REGULATORY REVIEW QUESTIONS ANSWERS
VERIFIED GUIDE
◉ 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 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:
, 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 upcoding
Service-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
REGULATORY REVIEW QUESTIONS ANSWERS
VERIFIED GUIDE
◉ 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 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:
, 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 upcoding
Service-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
