AHFI EXAM PREP UPDATED STUDY GUIDE
SOLVED QUESTIONS AND ANSWERS
◉ Anatomy of an investigation - 1) Detection - Case Management.
Answer: Includes:
*Behavioral & Pattern Analysis
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.
5) Kickbacks:
6) Upcoding: The improper practice of a medical professional billing
for a more expensive medical service than was actually provided to
the patient. The DOJ focuses on service-based, location-based or
time-based upcoding
7) Billing for unqualified workers:
◉ Upcoding.
Answer: The DOJ focuses on service-based, location-based and/or
time-based upcoding
Service-based upcoding: A doctor may perform a simple check-up,
but bill for a more extensive examination or even a surgery
Location-based upcoding: Billing for a procedure that occurred in an
operating room when, in fact, it had occurred in a less-expensive
setting such as an office
,Time-based-upcoding: When a doctor sees a patient for 10-minutes,
but bills for a more expensive 45-minute consultation.
◉ Robosigning.
Answer: Involves a doctor blindly writing Rx or order that authorize
care without first making an individualized determination of
medical necessity. (Opioids; home health care; power wheelchairs;
sleep studies) **The authorizing medical professional must make a
case-by-case analysis of medical necessity before ordering drugs or
services. And importantly, the company should be able to re-create
and affirmatively prove this process was actually used
◉ Billing for unqualified workers.
Answer: Unqualified or unlicensed workers.
Clinics using a less qualified worker (such as a P.A.) to render
services to a patient, but the services are billed as if they were
provided by a medical professional with a higher reimbursement
rate.
Or billing of lower-level medical professionals (physical therapy
assistants) who are supposed to be supervised by a higher-level
medical professional (a physical therapist) but operate without
supervision
, ◉ Kickbacks.
Answer: The payment of kickbacks or other illicit benefits to
patients, recruiters who procure such patients, or even to doctors or
other medical professionals..
Look for patients who are "frequent-flyers", or who present with a
number of different ailments over time that seem implausible
◉ Use of data in uncovering fraud.
Answer: Identifying geographic hotbeds for fraud (top biller in the
country for a specific code is not a good thing);
looking for a disconnect between the size of the medical practice and
the volume of billing;
inconguity between the practice's specialty and the types of codes
billed;
Rx for high % of opioids
◉ Home Health Fraud.
Answer: Hot-spots: South Forida, Detroit, TX, IL)
SOLVED QUESTIONS AND ANSWERS
◉ Anatomy of an investigation - 1) Detection - Case Management.
Answer: Includes:
*Behavioral & Pattern Analysis
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.
5) Kickbacks:
6) Upcoding: The improper practice of a medical professional billing
for a more expensive medical service than was actually provided to
the patient. The DOJ focuses on service-based, location-based or
time-based upcoding
7) Billing for unqualified workers:
◉ Upcoding.
Answer: The DOJ focuses on service-based, location-based and/or
time-based upcoding
Service-based upcoding: A doctor may perform a simple check-up,
but bill for a more extensive examination or even a surgery
Location-based upcoding: Billing for a procedure that occurred in an
operating room when, in fact, it had occurred in a less-expensive
setting such as an office
,Time-based-upcoding: When a doctor sees a patient for 10-minutes,
but bills for a more expensive 45-minute consultation.
◉ Robosigning.
Answer: Involves a doctor blindly writing Rx or order that authorize
care without first making an individualized determination of
medical necessity. (Opioids; home health care; power wheelchairs;
sleep studies) **The authorizing medical professional must make a
case-by-case analysis of medical necessity before ordering drugs or
services. And importantly, the company should be able to re-create
and affirmatively prove this process was actually used
◉ Billing for unqualified workers.
Answer: Unqualified or unlicensed workers.
Clinics using a less qualified worker (such as a P.A.) to render
services to a patient, but the services are billed as if they were
provided by a medical professional with a higher reimbursement
rate.
Or billing of lower-level medical professionals (physical therapy
assistants) who are supposed to be supervised by a higher-level
medical professional (a physical therapist) but operate without
supervision
, ◉ Kickbacks.
Answer: The payment of kickbacks or other illicit benefits to
patients, recruiters who procure such patients, or even to doctors or
other medical professionals..
Look for patients who are "frequent-flyers", or who present with a
number of different ailments over time that seem implausible
◉ Use of data in uncovering fraud.
Answer: Identifying geographic hotbeds for fraud (top biller in the
country for a specific code is not a good thing);
looking for a disconnect between the size of the medical practice and
the volume of billing;
inconguity between the practice's specialty and the types of codes
billed;
Rx for high % of opioids
◉ Home Health Fraud.
Answer: Hot-spots: South Forida, Detroit, TX, IL)
