AHFI (ACCREDITED HEALTH CARE
FRAUD INVESTIGATOR) ADVANCED
PROFESSIONAL EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Under the False Claims Act (FCA), what is the legal standard for ‘knowledge’ regarding the
submission of false claims?
A. Actual knowledge, deliberate ignorance, or reckless disregard for the truth.
B. Specific intent to defraud the government must be proven.
C. Simple negligence in the billing and coding process.
D. Only physical evidence of a written conspiracy to submit false bills.
Answer: A
Conceptual Explanation: The FCA defines ‘knowing’ and ‘knowingly’ to include actual
knowledge, deliberate ignorance, or reckless disregard. It specifically states that no proof of
specific intent to defraud is required.
2. Which of the following best describes the practice of ‘Unbundling’ in medical billing?
A. Submitting separate bills for components of a procedure that should be billed under a
single comprehensive code.
,B. Billing for services that were never rendered to the patient.
C. Reporting a higher level of service than what was actually performed.
D. Providing unnecessary medical tests to increase the total reimbursement.
Answer: A
Conceptual Explanation: Unbundling involves fragmenting a single procedure into
multiple component parts and billing each separately to capture a higher total
reimbursement than the global fee allows.
3. The Anti-Kickback Statute (AKS) differs from the Stark Law in which primary way?
A. AKS is a criminal statute requiring intent, while Stark Law is a civil, strict liability statute
regarding physician self-referrals.
B. AKS applies only to Medicare, while Stark Law applies to all federal healthcare programs.
C. AKS is a strict liability statute, while Stark Law requires intent.
D. There is no difference; they are two names for the same federal law.
Answer: A
Conceptual Explanation: The AKS is a criminal law that requires proof of intent to
exchange remuneration for referrals. The Stark Law is a civil law that prohibits physician
self-referrals for designated health services regardless of intent.
, 4. In a ‘Qui Tam’ action, the individual who brings the lawsuit on behalf of the government is
known as a:
A. Respondent
B. Relator
C. Adjudicator
D. Beneficiary
Answer: B
Conceptual Explanation: A ‘relator’ is the private party (whistleblower) who files a False
Claims Act lawsuit on behalf of the U.S. government.
5. Which data analysis technique is most effective for detecting ‘phantom billing’ across a
high volume of claims?
A. Comparing provider billing patterns against peer groups using standard deviation
analysis.
B. Manual chart review of every 100th patient.
C. Interviewing patients at random regarding their last visit.
D. Verifying the medical degree of the provider in question.
Answer: A
FRAUD INVESTIGATOR) ADVANCED
PROFESSIONAL EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Under the False Claims Act (FCA), what is the legal standard for ‘knowledge’ regarding the
submission of false claims?
A. Actual knowledge, deliberate ignorance, or reckless disregard for the truth.
B. Specific intent to defraud the government must be proven.
C. Simple negligence in the billing and coding process.
D. Only physical evidence of a written conspiracy to submit false bills.
Answer: A
Conceptual Explanation: The FCA defines ‘knowing’ and ‘knowingly’ to include actual
knowledge, deliberate ignorance, or reckless disregard. It specifically states that no proof of
specific intent to defraud is required.
2. Which of the following best describes the practice of ‘Unbundling’ in medical billing?
A. Submitting separate bills for components of a procedure that should be billed under a
single comprehensive code.
,B. Billing for services that were never rendered to the patient.
C. Reporting a higher level of service than what was actually performed.
D. Providing unnecessary medical tests to increase the total reimbursement.
Answer: A
Conceptual Explanation: Unbundling involves fragmenting a single procedure into
multiple component parts and billing each separately to capture a higher total
reimbursement than the global fee allows.
3. The Anti-Kickback Statute (AKS) differs from the Stark Law in which primary way?
A. AKS is a criminal statute requiring intent, while Stark Law is a civil, strict liability statute
regarding physician self-referrals.
B. AKS applies only to Medicare, while Stark Law applies to all federal healthcare programs.
C. AKS is a strict liability statute, while Stark Law requires intent.
D. There is no difference; they are two names for the same federal law.
Answer: A
Conceptual Explanation: The AKS is a criminal law that requires proof of intent to
exchange remuneration for referrals. The Stark Law is a civil law that prohibits physician
self-referrals for designated health services regardless of intent.
, 4. In a ‘Qui Tam’ action, the individual who brings the lawsuit on behalf of the government is
known as a:
A. Respondent
B. Relator
C. Adjudicator
D. Beneficiary
Answer: B
Conceptual Explanation: A ‘relator’ is the private party (whistleblower) who files a False
Claims Act lawsuit on behalf of the U.S. government.
5. Which data analysis technique is most effective for detecting ‘phantom billing’ across a
high volume of claims?
A. Comparing provider billing patterns against peer groups using standard deviation
analysis.
B. Manual chart review of every 100th patient.
C. Interviewing patients at random regarding their last visit.
D. Verifying the medical degree of the provider in question.
Answer: A
