AHFI PRACTICE TEST EXAM QUESTIONS AND CORRECT ANSWERS (VERIFIED ANSWERS) PLUS
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains*
*1. Healthcare Fraud and Abuse Laws*
*2. Coding, Billing, and Reimbursement*
*3. Data Analysis and Pattern Recognition*
*4. Investigation Techniques and Evidence*
*5. Provider and Pharmacy Fraud Schemes*
*6. Ethics and Professional Standards*
*7. Regulatory Compliance and Reporting*
*8. Investigative Interviewing Strategies*
*Introduction*
*The Accredited Healthcare Fraud Investigator (AHFI) exam is designed to rigorously evaluate a ca
SECTION ONE: QUESTIONS 1–100
Which federal law prohibits the knowing and willful offer or payment of remuneration to induce the
referral of services reimbursable by a federal healthcare program?
A. False Claims Act
B. Anti-Kickback Statute
🟢 C. Stark Law
D. Civil Monetary Penalties Law
,🔴 RATIONALE: The Anti-Kickback Statute (AKS) is a criminal statute that prohibits the exchange
of anything of value to reward the referral of federal healthcare program business.
A provider submits a claim for a high-level evaluation and management (E/M) code when only a
brief, low-level service was provided. This is an example of:
A. Unbundling
B. Double billing
🔴 C. Upcoding
D. Phantom billing
🔴 RATIONALE: Upcoding occurs when a provider submits codes for more expensive services or
procedures than those actually performed to increase reimbursement.
Under the False Claims Act (FCA), what is the term for a private person bringing a lawsuit on behalf
of the government?
A. Subpoena
B. Affidavit
C. Qui tam
🟢 D. Indictment
🔴 RATIONALE: A qui tam action allows a whistleblower (relator) to file a lawsuit on behalf of the
government and share in any recovery.
When analyzing pharmacy data, which of the following is a "red flag" for potential drug diversion?
A. Prescriptions for generic medications
B. Patients using multiple pharmacies within the same network
🟢 C. Patterns of controlled substances dispensed in quantities exceeding clinical necessity
D. Consistent use of mail-order pharmacies
🔴 RATIONALE: Dispensing patterns that deviate from clinical norms or standard treatment
guidelines for controlled substances often indicate diversion or "pill mill" activity.
, Which entity is primarily responsible for the administration of the Medicare program?
A. Office of Inspector General (OIG)
B. Department of Justice (DOJ)
🟢 C. Centers for Medicare & Medicaid Services (CMS)
D. Federal Bureau of Investigation (FBI)
🔴 RATIONALE: CMS is the federal agency within the Department of Health and Human Services
that oversees the administration of Medicare, Medicaid, and CHIP.
What is the primary purpose of a "look-back" audit?
A. To verify patient insurance eligibility
B. To identify overpayments and potential fraud over a historical period
🟢 C. To determine future premium adjustments
D. To validate provider credentials
🔴 RATIONALE: Look-back audits are retrospective reviews designed to identify patterns of
improper billing or overpayments made to providers over a specific duration.
Which of the following is considered an "administrative" safeguard under HIPAA?
A. Access control software
B. Biometric locks
🟢 C. Security awareness and training programs
D. Facility security plans
🔴 RATIONALE: Administrative safeguards represent the policies and procedures designed to
manage the selection, development, implementation, and maintenance of security measures to
protect ePHI.
A provider submits separate claims for individual components of a procedure that should be billed
under a single comprehensive code. This is known as:
A. Upcoding
RATIONALES 2026 Q&A | INSTANT DOWNLOAD PDF.
*Core Domains*
*1. Healthcare Fraud and Abuse Laws*
*2. Coding, Billing, and Reimbursement*
*3. Data Analysis and Pattern Recognition*
*4. Investigation Techniques and Evidence*
*5. Provider and Pharmacy Fraud Schemes*
*6. Ethics and Professional Standards*
*7. Regulatory Compliance and Reporting*
*8. Investigative Interviewing Strategies*
*Introduction*
*The Accredited Healthcare Fraud Investigator (AHFI) exam is designed to rigorously evaluate a ca
SECTION ONE: QUESTIONS 1–100
Which federal law prohibits the knowing and willful offer or payment of remuneration to induce the
referral of services reimbursable by a federal healthcare program?
A. False Claims Act
B. Anti-Kickback Statute
🟢 C. Stark Law
D. Civil Monetary Penalties Law
,🔴 RATIONALE: The Anti-Kickback Statute (AKS) is a criminal statute that prohibits the exchange
of anything of value to reward the referral of federal healthcare program business.
A provider submits a claim for a high-level evaluation and management (E/M) code when only a
brief, low-level service was provided. This is an example of:
A. Unbundling
B. Double billing
🔴 C. Upcoding
D. Phantom billing
🔴 RATIONALE: Upcoding occurs when a provider submits codes for more expensive services or
procedures than those actually performed to increase reimbursement.
Under the False Claims Act (FCA), what is the term for a private person bringing a lawsuit on behalf
of the government?
A. Subpoena
B. Affidavit
C. Qui tam
🟢 D. Indictment
🔴 RATIONALE: A qui tam action allows a whistleblower (relator) to file a lawsuit on behalf of the
government and share in any recovery.
When analyzing pharmacy data, which of the following is a "red flag" for potential drug diversion?
A. Prescriptions for generic medications
B. Patients using multiple pharmacies within the same network
🟢 C. Patterns of controlled substances dispensed in quantities exceeding clinical necessity
D. Consistent use of mail-order pharmacies
🔴 RATIONALE: Dispensing patterns that deviate from clinical norms or standard treatment
guidelines for controlled substances often indicate diversion or "pill mill" activity.
, Which entity is primarily responsible for the administration of the Medicare program?
A. Office of Inspector General (OIG)
B. Department of Justice (DOJ)
🟢 C. Centers for Medicare & Medicaid Services (CMS)
D. Federal Bureau of Investigation (FBI)
🔴 RATIONALE: CMS is the federal agency within the Department of Health and Human Services
that oversees the administration of Medicare, Medicaid, and CHIP.
What is the primary purpose of a "look-back" audit?
A. To verify patient insurance eligibility
B. To identify overpayments and potential fraud over a historical period
🟢 C. To determine future premium adjustments
D. To validate provider credentials
🔴 RATIONALE: Look-back audits are retrospective reviews designed to identify patterns of
improper billing or overpayments made to providers over a specific duration.
Which of the following is considered an "administrative" safeguard under HIPAA?
A. Access control software
B. Biometric locks
🟢 C. Security awareness and training programs
D. Facility security plans
🔴 RATIONALE: Administrative safeguards represent the policies and procedures designed to
manage the selection, development, implementation, and maintenance of security measures to
protect ePHI.
A provider submits separate claims for individual components of a procedure that should be billed
under a single comprehensive code. This is known as:
A. Upcoding
