ACCREDITED HEALTH CARE FRAUD
INVESTIGATOR (AHFI)
COMPREHENSIVE EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Which of the following best describes ‘upcoding’ in medical billing?
A. Submitting multiple CPT codes for procedures that should be covered by a single
comprehensive code.
B. Billing for a more expensive service than the one actually performed to increase
reimbursement.
C. Billing for services that were never rendered to the patient.
D. Providing services that are not medically necessary based on the patient’s diagnosis.
Answer: B
Conceptual Explanation: Upcoding occurs when a provider submits a claim for a higher
level of service or a more complex procedure than was actually performed, resulting in
higher reimbursement.
2. What is the primary difference between the False Claims Act (FCA) and the Anti-Kickback
Statute (AKS)?
A. The FCA is strictly a criminal statute, whereas the AKS is only civil.
,B. The FCA focuses on the submission of false claims, while the AKS focuses on illegal
remuneration for referrals.
C. The FCA requires proof of specific intent to defraud, while the AKS does not.
D. The FCA applies only to Medicare, while the AKS applies to all private insurance.
Answer: B
Conceptual Explanation: The False Claims Act addresses the submission of fraudulent
claims for payment to the government, while the Anti-Kickback Statute prohibits offering
or receiving anything of value to induce referrals for services paid by federal programs.
3. In the context of healthcare fraud, what does ‘unbundling’ refer to?
A. Billing for services provided by a non-physician under a physician’s NPI.
B. Combining multiple codes into one global code to simplify billing.
C. Separating components of a procedure and billing them as individual codes to increase
payment.
D. Billing for equipment that was never delivered to the patient.
Answer: C
Conceptual Explanation: Unbundling is the practice of billing separately for multiple
components of a service that should be billed under a single comprehensive ‘bundled’ code.
, 4. Which legal provision allows a private individual to file a lawsuit on behalf of the
government for fraud?
A. Qui Tam provisions of the False Claims Act
B. Stark Law exceptions
C. Safe Harbor regulations
D. The HIPAA Privacy Rule
Answer: A
Conceptual Explanation: Qui tam provisions allow ‘whistleblowers’ (relators) to sue on
behalf of the government and potentially receive a portion of the recovered funds.
5. The Stark Law is also known as:
A. The Civil Monetary Penalties Law
B. The Physician Self-Referral Law
C. The Health Care Fraud Statute
D. The Anti-Fraud Amendment
Answer: B
Conceptual Explanation: The Stark Law prohibits physicians from referring patients for
designated health services to entities with which the physician has a financial relationship,
unless an exception applies.
INVESTIGATOR (AHFI)
COMPREHENSIVE EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Which of the following best describes ‘upcoding’ in medical billing?
A. Submitting multiple CPT codes for procedures that should be covered by a single
comprehensive code.
B. Billing for a more expensive service than the one actually performed to increase
reimbursement.
C. Billing for services that were never rendered to the patient.
D. Providing services that are not medically necessary based on the patient’s diagnosis.
Answer: B
Conceptual Explanation: Upcoding occurs when a provider submits a claim for a higher
level of service or a more complex procedure than was actually performed, resulting in
higher reimbursement.
2. What is the primary difference between the False Claims Act (FCA) and the Anti-Kickback
Statute (AKS)?
A. The FCA is strictly a criminal statute, whereas the AKS is only civil.
,B. The FCA focuses on the submission of false claims, while the AKS focuses on illegal
remuneration for referrals.
C. The FCA requires proof of specific intent to defraud, while the AKS does not.
D. The FCA applies only to Medicare, while the AKS applies to all private insurance.
Answer: B
Conceptual Explanation: The False Claims Act addresses the submission of fraudulent
claims for payment to the government, while the Anti-Kickback Statute prohibits offering
or receiving anything of value to induce referrals for services paid by federal programs.
3. In the context of healthcare fraud, what does ‘unbundling’ refer to?
A. Billing for services provided by a non-physician under a physician’s NPI.
B. Combining multiple codes into one global code to simplify billing.
C. Separating components of a procedure and billing them as individual codes to increase
payment.
D. Billing for equipment that was never delivered to the patient.
Answer: C
Conceptual Explanation: Unbundling is the practice of billing separately for multiple
components of a service that should be billed under a single comprehensive ‘bundled’ code.
, 4. Which legal provision allows a private individual to file a lawsuit on behalf of the
government for fraud?
A. Qui Tam provisions of the False Claims Act
B. Stark Law exceptions
C. Safe Harbor regulations
D. The HIPAA Privacy Rule
Answer: A
Conceptual Explanation: Qui tam provisions allow ‘whistleblowers’ (relators) to sue on
behalf of the government and potentially receive a portion of the recovered funds.
5. The Stark Law is also known as:
A. The Civil Monetary Penalties Law
B. The Physician Self-Referral Law
C. The Health Care Fraud Statute
D. The Anti-Fraud Amendment
Answer: B
Conceptual Explanation: The Stark Law prohibits physicians from referring patients for
designated health services to entities with which the physician has a financial relationship,
unless an exception applies.
