AHFI EXAM MASTERY: HEALTH CARE
FRAUD INVESTIGATION
COMPREHENSIVE REVIEW COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Under the False Claims Act (FCA), what is the legal standard for ‘knowing’ or ‘knowingly’
regarding the submission of a false claim?
A. Specific intent to defraud the government is required.
B. Only actual knowledge of the falsity of the claim.
C. Actual knowledge, deliberate ignorance, or reckless disregard for the truth.
D. Simple negligence or accidental billing errors.
Answer: C
Conceptual Explanation: The FCA defines ‘knowing’ to include actual knowledge, acting in
deliberate ignorance of the truth, or acting in reckless disregard of the truth; it does not
require specific intent to defraud.
2. Which federal statute is a ‘strict liability’ law, meaning no proof of intent to violate the law
is required?
A. Federal Anti-Kickback Statute
,B. Stark Law (Physician Self-Referral Law)
C. Health Insurance Portability and Accountability Act (HIPAA)
D. Civil Monetary Penalties Law (CMPL)
Answer: B
Conceptual Explanation: The Stark Law is a strict liability statute, meaning that if a
financial relationship exists and a referral occurs that does not meet an exception, a
violation has occurred regardless of intent.
3. In the context of health care fraud, what does the term ‘unbundling’ specifically refer to?
A. Billing for a higher level of service than was actually provided.
B. Fragmenting a comprehensive procedure code into multiple component codes to
increase reimbursement.
C. Billing for services that were never rendered to the patient.
D. Billing twice for the same service on the same date.
Answer: B
Conceptual Explanation: Unbundling involves separating the components of a procedure
and billing for them individually when a single comprehensive code should have been used,
resulting in higher payments.
, 4. What is the primary difference between the Anti-Kickback Statute (AKS) and the Stark
Law?
A. AKS requires no intent; Stark requires specific intent.
B. AKS is a civil law; Stark is a criminal law.
C. Stark applies to all federal health programs; AKS applies only to Medicare.
D. AKS applies to any referral source; Stark applies only to physician referrals for
designated health services.
Answer: D
Conceptual Explanation: The AKS is broad and covers any person who offers or receives
remuneration for referrals, while Stark is specific to physician referrals for Designated
Health Services (DHS) to entities with which they have a financial relationship.
5. Which of the following is considered ‘remuneration’ under the Anti-Kickback Statute?
A. Cash payments only.
B. All of the above.
C. Excessive compensation for consulting services.
D. Free or discounted rent or equipment.
Answer: B
FRAUD INVESTIGATION
COMPREHENSIVE REVIEW COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS
LATEST UPDATE
1. Under the False Claims Act (FCA), what is the legal standard for ‘knowing’ or ‘knowingly’
regarding the submission of a false claim?
A. Specific intent to defraud the government is required.
B. Only actual knowledge of the falsity of the claim.
C. Actual knowledge, deliberate ignorance, or reckless disregard for the truth.
D. Simple negligence or accidental billing errors.
Answer: C
Conceptual Explanation: The FCA defines ‘knowing’ to include actual knowledge, acting in
deliberate ignorance of the truth, or acting in reckless disregard of the truth; it does not
require specific intent to defraud.
2. Which federal statute is a ‘strict liability’ law, meaning no proof of intent to violate the law
is required?
A. Federal Anti-Kickback Statute
,B. Stark Law (Physician Self-Referral Law)
C. Health Insurance Portability and Accountability Act (HIPAA)
D. Civil Monetary Penalties Law (CMPL)
Answer: B
Conceptual Explanation: The Stark Law is a strict liability statute, meaning that if a
financial relationship exists and a referral occurs that does not meet an exception, a
violation has occurred regardless of intent.
3. In the context of health care fraud, what does the term ‘unbundling’ specifically refer to?
A. Billing for a higher level of service than was actually provided.
B. Fragmenting a comprehensive procedure code into multiple component codes to
increase reimbursement.
C. Billing for services that were never rendered to the patient.
D. Billing twice for the same service on the same date.
Answer: B
Conceptual Explanation: Unbundling involves separating the components of a procedure
and billing for them individually when a single comprehensive code should have been used,
resulting in higher payments.
, 4. What is the primary difference between the Anti-Kickback Statute (AKS) and the Stark
Law?
A. AKS requires no intent; Stark requires specific intent.
B. AKS is a civil law; Stark is a criminal law.
C. Stark applies to all federal health programs; AKS applies only to Medicare.
D. AKS applies to any referral source; Stark applies only to physician referrals for
designated health services.
Answer: D
Conceptual Explanation: The AKS is broad and covers any person who offers or receives
remuneration for referrals, while Stark is specific to physician referrals for Designated
Health Services (DHS) to entities with which they have a financial relationship.
5. Which of the following is considered ‘remuneration’ under the Anti-Kickback Statute?
A. Cash payments only.
B. All of the above.
C. Excessive compensation for consulting services.
D. Free or discounted rent or equipment.
Answer: B
