AHFI Examination Prep Course Exam
2026 Questions and Answers
HCF Investigator Assumptions - Answer -*General knowledge of the Health care
Delivery System
*Health plan policy and procedures relative to the delivery of services
*Able to identify Red Flags, behaviors & indicators of health care fraud schemes
Know applicable federal & state laws related to health care fraud
*Law enforcement & regulatory agencies that have oversight responsibilities for
HCF
*Local & regional investigative groups that have similar interests
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,Fraud, by it's very nature, is decptive. - Answer -As such, nobody really knows
what the impact and cost of fraud is. However there are some common industry
estimates
Conservative US Healthcare spending in 2015 was $3.2Trillion
Conservative estimate of fraud is 3-5% (means tens of billions of dollars each year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between 5% and
10%)
Anatomy of an investigation - Answer -Each fraud case is unique, however, under
the surface of the specific schemes, all HCF investigatons have a common
structure, or process.
Anatomy of an investigation - 1) Detection - Answer -The process of uncovering
potential fraud waste and abuse utilizing human and technical resources and
techniques
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,Anatomy of an investigation - 2) Assessment - Answer -The primary objective of
the assessment phase is to establish PREDICATION for the continued
investigation
Predication - Answer -to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Answer -Devoloping an
investigative plan to identify and gather evidence to support the statuatory
elements to prove
Anatomy of an investigation - 4) Case Investigation - Answer -The process of
utilizing legal and appropriate techniques to prove or disprove the allegations
Antomy of an investigation - 5) Report Writing - Answer -The process of
documenting the investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - Answer -Evaluating the
totality of the documented case facts to determine the best action to resolve the
investigation.
Anatomy of an investigation - 1) Detection - Case Management - Answer -
Includes:
*Behavioral & Pattern Analysis
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, Emergings Schemes - being familiar enough with new schemes to be able to
recognize that something is "off"
"Hot Spots": Know where the "hot-spots" are in the country
The top Red Flags for Health Care Fraud in 2018 - Answer -1) Opioids: 12
hotspots (Florida, Tennessee, Alaska, Texas); focus investigations and prosecuting
"pill mills" (pharmacies that improperly divert and dispense Rx opioid and other
opioid-related issues)
2) Home Health Care:
3) Use of data:
4) Robosigning: Involves a doctor blindly writing Rx or order that authorize care
without first making an individualized determination of medical necessity.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
2026 Questions and Answers
HCF Investigator Assumptions - Answer -*General knowledge of the Health care
Delivery System
*Health plan policy and procedures relative to the delivery of services
*Able to identify Red Flags, behaviors & indicators of health care fraud schemes
Know applicable federal & state laws related to health care fraud
*Law enforcement & regulatory agencies that have oversight responsibilities for
HCF
*Local & regional investigative groups that have similar interests
©COPYRIGHT 2025, ALL RIGHTS RESERVED 1
,Fraud, by it's very nature, is decptive. - Answer -As such, nobody really knows
what the impact and cost of fraud is. However there are some common industry
estimates
Conservative US Healthcare spending in 2015 was $3.2Trillion
Conservative estimate of fraud is 3-5% (means tens of billions of dollars each year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between 5% and
10%)
Anatomy of an investigation - Answer -Each fraud case is unique, however, under
the surface of the specific schemes, all HCF investigatons have a common
structure, or process.
Anatomy of an investigation - 1) Detection - Answer -The process of uncovering
potential fraud waste and abuse utilizing human and technical resources and
techniques
©COPYRIGHT 2025, ALL RIGHTS RESERVED 2
,Anatomy of an investigation - 2) Assessment - Answer -The primary objective of
the assessment phase is to establish PREDICATION for the continued
investigation
Predication - Answer -to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Answer -Devoloping an
investigative plan to identify and gather evidence to support the statuatory
elements to prove
Anatomy of an investigation - 4) Case Investigation - Answer -The process of
utilizing legal and appropriate techniques to prove or disprove the allegations
Antomy of an investigation - 5) Report Writing - Answer -The process of
documenting the investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - Answer -Evaluating the
totality of the documented case facts to determine the best action to resolve the
investigation.
Anatomy of an investigation - 1) Detection - Case Management - Answer -
Includes:
*Behavioral & Pattern Analysis
©COPYRIGHT 2025, ALL RIGHTS RESERVED 3
, Emergings Schemes - being familiar enough with new schemes to be able to
recognize that something is "off"
"Hot Spots": Know where the "hot-spots" are in the country
The top Red Flags for Health Care Fraud in 2018 - Answer -1) Opioids: 12
hotspots (Florida, Tennessee, Alaska, Texas); focus investigations and prosecuting
"pill mills" (pharmacies that improperly divert and dispense Rx opioid and other
opioid-related issues)
2) Home Health Care:
3) Use of data:
4) Robosigning: Involves a doctor blindly writing Rx or order that authorize care
without first making an individualized determination of medical necessity.
©COPYRIGHT 2025, ALL RIGHTS RESERVED 4
