ACCREDITED HEALTH CARE FRAUD
INVESTIGATOR (AHFI) PROFESSIONAL
EXAM COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, what is the ‘scienter’ requirement for establishing liability?
A. Proof of specific intent to defraud the government
B. Actual knowledge, deliberate ignorance, or reckless disregard of the truth
C. Simple negligence in billing practices
D. Malicious intent to harm the Medicare Trust Fund
Answer: B
Conceptual Explanation: The False Claims Act does not require proof of specific intent to
defraud. It defines ‘knowing’ to include actual knowledge, deliberate ignorance, or reckless
disregard.
2. Which legal doctrine allows a private individual to file a lawsuit on behalf of the
government?
A. Respondeat superior
B. Caveat emptor
,C. Qui tam
D. Stare decisis
Answer: C
Conceptual Explanation: Qui tam provisions of the False Claims Act allow ‘relators’
(whistleblowers) to sue on behalf of the government and share in the recovery.
3. The ‘One Purpose’ rule, established in United States v. Greber, applies to which statute?
A. Anti-Kickback Statute
B. False Claims Act
C. Stark Law
D. Health Insurance Portability and Accountability Act
Answer: A
Conceptual Explanation: The One Purpose rule states that if even one purpose of a
payment is to induce referrals, the Anti-Kickback Statute is violated, even if the payment
was also for legitimate services.
4. Which of the following describes ‘unbundling’ in medical coding fraud?
A. Reporting a higher level of service than actually performed
B. Billing for services never rendered to the patient
C. Billing multiple CPT codes for components of a procedure that should be covered by a
single comprehensive code
, D. Using a modifier to bypass National Correct Coding Initiative (NCCI) edits
Answer: C
Conceptual Explanation: Unbundling involves fragmenting a single procedure into
multiple component parts to increase reimbursement, which is a fraudulent practice.
5. In the context of the Stark Law, which of the following is true?
A. It is a criminal statute requiring proof of intent
B. It applies to any healthcare service regardless of the payer
C. It is a strict liability statute, meaning intent is irrelevant
D. It covers referrals for all medical services, including office supplies
Answer: C
Conceptual Explanation: Stark Law is a civil, strict liability statute; if a financial
relationship exists and no exception is met, a violation occurs regardless of intent.
6. Which statistical method is most commonly used by investigators to identify outliers in
billing patterns by looking at the frequency of digits?
A. Benford’s Law
B. Linear Regression
C. Standard Deviation Analysis
D. Monte Carlo Simulation
INVESTIGATOR (AHFI) PROFESSIONAL
EXAM COMPLETE QUESTIONS AND
VERIFIED SOLUTIONS LATEST
UPDATE
1. Under the False Claims Act, what is the ‘scienter’ requirement for establishing liability?
A. Proof of specific intent to defraud the government
B. Actual knowledge, deliberate ignorance, or reckless disregard of the truth
C. Simple negligence in billing practices
D. Malicious intent to harm the Medicare Trust Fund
Answer: B
Conceptual Explanation: The False Claims Act does not require proof of specific intent to
defraud. It defines ‘knowing’ to include actual knowledge, deliberate ignorance, or reckless
disregard.
2. Which legal doctrine allows a private individual to file a lawsuit on behalf of the
government?
A. Respondeat superior
B. Caveat emptor
,C. Qui tam
D. Stare decisis
Answer: C
Conceptual Explanation: Qui tam provisions of the False Claims Act allow ‘relators’
(whistleblowers) to sue on behalf of the government and share in the recovery.
3. The ‘One Purpose’ rule, established in United States v. Greber, applies to which statute?
A. Anti-Kickback Statute
B. False Claims Act
C. Stark Law
D. Health Insurance Portability and Accountability Act
Answer: A
Conceptual Explanation: The One Purpose rule states that if even one purpose of a
payment is to induce referrals, the Anti-Kickback Statute is violated, even if the payment
was also for legitimate services.
4. Which of the following describes ‘unbundling’ in medical coding fraud?
A. Reporting a higher level of service than actually performed
B. Billing for services never rendered to the patient
C. Billing multiple CPT codes for components of a procedure that should be covered by a
single comprehensive code
, D. Using a modifier to bypass National Correct Coding Initiative (NCCI) edits
Answer: C
Conceptual Explanation: Unbundling involves fragmenting a single procedure into
multiple component parts to increase reimbursement, which is a fraudulent practice.
5. In the context of the Stark Law, which of the following is true?
A. It is a criminal statute requiring proof of intent
B. It applies to any healthcare service regardless of the payer
C. It is a strict liability statute, meaning intent is irrelevant
D. It covers referrals for all medical services, including office supplies
Answer: C
Conceptual Explanation: Stark Law is a civil, strict liability statute; if a financial
relationship exists and no exception is met, a violation occurs regardless of intent.
6. Which statistical method is most commonly used by investigators to identify outliers in
billing patterns by looking at the frequency of digits?
A. Benford’s Law
B. Linear Regression
C. Standard Deviation Analysis
D. Monte Carlo Simulation
