AHFI Examination Prep Course REVISED AND
UPDATED FOR 2026/2027 ACTUAL EXAM
COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW!!
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Terms in this set (141)
HCF Investigator Assumptions *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 As such, nobody really knows what the impact
decptive. 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 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) The process of uncovering potential fraud waste
Detection and abuse utilizing human and technical
resources and techniques
Anatomy of an investigation - 2) The primary objective of the assessment phase is
Assessment to establish PREDICATION for the continued
investigation
Predication to proclaim; declare; assert
,Anatomy of an Investigation - 3) Devoloping an investigative plan to identify and
Investigative Strategy gather evidence to support the statuatory
elements to prove
Anatomy of an investigation - 4) The process of utilizing legal and appropriate
Case Investigation techniques to prove or disprove the allegations
Antomy of an investigation - 5) The process of documenting the investigative
Report Writing tasks in a final comprehensive investigative
report.
Anatomy of an investigation - 6) Evaluating the totality of the documented case
Determination of action facts to determine the best action to resolve the
investigation.
Anatomy of an investigation - 1) Includes:
Detection - Case Management
*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 1) Opioids: 12 hotspots (Florida, Tennessee,
Fraud in 2018 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:
UPDATED FOR 2026/2027 ACTUAL EXAM
COMPLETE QUESTIONS AND CORRECT
DETAILED ANSWERS (VERIFIED ANSWERS)
|ALREADY GRADED A+||BRAND NEW!!
Save
Terms in this set (141)
HCF Investigator Assumptions *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 As such, nobody really knows what the impact
decptive. 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 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) The process of uncovering potential fraud waste
Detection and abuse utilizing human and technical
resources and techniques
Anatomy of an investigation - 2) The primary objective of the assessment phase is
Assessment to establish PREDICATION for the continued
investigation
Predication to proclaim; declare; assert
,Anatomy of an Investigation - 3) Devoloping an investigative plan to identify and
Investigative Strategy gather evidence to support the statuatory
elements to prove
Anatomy of an investigation - 4) The process of utilizing legal and appropriate
Case Investigation techniques to prove or disprove the allegations
Antomy of an investigation - 5) The process of documenting the investigative
Report Writing tasks in a final comprehensive investigative
report.
Anatomy of an investigation - 6) Evaluating the totality of the documented case
Determination of action facts to determine the best action to resolve the
investigation.
Anatomy of an investigation - 1) Includes:
Detection - Case Management
*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 1) Opioids: 12 hotspots (Florida, Tennessee,
Fraud in 2018 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:
