AHFI Exam Questions With 100 % Correct Answers | Latest Updated 2026/2027 | Guaranteed Success

AHFI Exam Questions With 100 % Correct Answers | Latest Updated 2026/2027 | Guaranteed Success Anti-Kickback Statute (42 US SS 1320a-7b (b) prohibitions - answer-Prohibits offering, paying, soliciting or reviving anything of value to induce or reward referrals or generate Federal health care program business Anti-Kickback Statute (42 US SS 1320a-7b (b) referrals - answer-Referrals from anyone Anti-Kickback Statute (42 US SS 1320a-7b (b) - answer-Any items or services Anti-Kickback Statute (42 US SS 1320a-7b (b) (Intent) - answer-Intent MUST be proven (knowing and willful) Anti-Kickback Statute (42 US SS 1320a-7b (b) Criminal penalties - answer-Fines up to $25,000/violation Up to a 5-yr prison term/violation Anti-Kickback Statute (42 US SS 1320a-7b (b) (Civil/administrative) - answer-False Claims act liability Civil monetary penalties and program exclusions Potential $50,000 CMP/violationCivil assessment of up to 3x amount of kickback Anti-Kickback Statute (42 US SS 1320a-7b (b) Exceptions - answer-Voluntary safe harbors Anti-Kickback Statute (42 US SS 1320a-7b (b) - what it applies to... - answer-All Federal Health Care Programs The Stark Law (42 US SS 139nn) Prohibition - answer-Prohibits a physician from referring Medicare patients for designated health services to an entity with which the physician (or immediate family member) has a financial relationship, unless an exception applies) Prohibits the designated health services entity from submitting claims to Medicare for those services resulting from a prohibited referral The Stark Law (42 US SS 139nn) Referrals - answer-Referrals from a physician The Stark Law (42 US SS 139nn) (Items/Services) - answer-Designated health services The Stark Law (42 US SS 139nn) (Intent) - answer-No intent standard for overpayment (strict liability) Intent required for civil monetary penalties for knowing violations The Stark Law (42 US SS 139nn) (Civil Penalties) only - answer-Overpayment/refund obligation False Claims Act liabilityCivil monetary penalties and program exclusion for knowing violations Potential $15,000 CMP for each service Civil assessment of up to 3x the amount claimed. The Stark Law (42 US SS 139nn) (Exceptions) - answer-Mandatory exceptions The Stark Law (42 US SS 139nn) applies to - answer-Medicare and Medicaid (No commercial or tricare) MACs: - answer-Medicare Administrative Contractors They analyze claims to determine provider compliance with Medicare coverage, coding, and billing rules and take appropriate corrective action when providers are found to be noncompliant. The goal of Mac administrative actions - answer-To correct the behavior in need of change and prevent future inappropriate billing The priority of MACs - answer-To minimize potential future losses to the Medicare Trust Fund through targeted claims review while using resource efficiently and treating providers and beneficiaries fairly.For repeated infractions, MACs have - answer-The discretion to initiate progressively more severe administrative action, commensurate with the seriousness of the identified problem. (See Program Integrity Manual (PIM) chapter 3, SS3. 7.1) Medicare Fee For Service Recovery Audit Program - answer-Legislative mandated program (Tax Relief and Health Care act of 2006) Utilizes Recovery Auditors to identify improper payments paid by Medicare to fee-for-service providers. Recovery Auditors identify improper payments MACs adjust the claims, recoup identified overpayment and return underpayment.s. MACs targeted provider-specific prepayment review - answer-The MACs shall initiate a targeted provider-specific prepayment review only when there is the likelihood of sustained or high level of payment error. MACs are encouraged to initiate service-s[ecific prepayment review to prevent improper payments for services identified by C ERT or Recovery Auditors as problem areas, as well as, problem areas identified by their own data analysis Cert Contractors and reviews - answer-Because the Cert Contractors select claims on a random basis, they are not required to notify providers of their intention to begin a review. Prepayment Review Time Frames: - answer-When requesting documentation for prepayment reviews, the Mac and ZPIC shall notify providers that the requested documentation is to be submitted within 45-calendar days of the request.The reviewer shall Not grant extensions to providers who need more time to comply with the request. Reviewers shall deny claims for which the requested documentation was not received by day 46. Postpayment Review Time Frames - answer-When requesting documentation for postpayment review, the Mac, Cert, and RAC shall notify providers that the requested documents are to be submitted with 45-calendar days of the request. ZPIC shall notify providers that requested documents are to be submitted with in 30-calendar days of the request. Additional Documentation Requests - answer-If information is requested from both the billing provider or supplier and a third party and no response is received from either within 45-calendar days for MACs and RACs Or 30-days for ZPICs/UPICs After the date of the request (or within a reasonable time following an extension), the MACs, RACs and ZPICs/UPICs shall deny the claim in full or in part as not reasonable and necessary. No response for request of prepayment - answer-During prepayment review, if no response is received within 45-calendar days after the date of the ADR (request for Additional Documentation Requests), the MACs and Zpics/UPICs shall deny the claim.No response for MACs and Cert for ADR - answer-If the MACs and Cert receive the requested information from a provider or supplier after a denial has been issued but within a reasonable number of days (generally 15-calendar days after the denial date), They have the discretion to reopen the claim. The primary authority for all coverage provisions and subsequent policies is - answer-The Social Security Act In general, MACs, Cert, Recovery Auditors, SMRCs and ZPICs us the following hierarchy of documents to make medical review decisions: - answer-1) Social Security Act 2) Code of Federal Regulations 3) CMS' Rulings 4) National Coverage Determinations (NCDs) 5) Coverage provisions in Interpretive Manuals or Internet Only Manuals (IOM) which includes Medical Review Guidance in the Medicare Program Integrity Manual 6) CMS coding policies 7)Technical Direction Letters (TDLs)8) The relevant Macs Local Coverage Determination (LCDs)