AHFI Prep Exam UPDATED QUESTIONS
AND CORRECT ANSWERS
HCF Investigator Assumptions - CORRECT 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
Fraud, by it's very nature, is decptive. - CORRECT 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 - CORRECT 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 - CORRECT ANSWER The process of
uncovering potential fraud waste and abuse utilizing human and technical resources and
techniques
Anatomy of an investigation - 2) Assessment - CORRECT ANSWER The primary
objective of the assessment phase is to establish PREDICATION for the continued
investigation
Predication - CORRECT ANSWER to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - CORRECT
ANSWER Devoloping an investigative plan to identify and gather evidence to support
the statuatory elements to prove
Anatomy of an investigation - 4) Case Investigation - CORRECT ANSWER The
process of utilizing legal and appropriate techniques to prove or disprove the allegations
Antomy of an investigation - 5) Report Writing - CORRECT ANSWER The process of
documenting the investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - CORRECT
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 - CORRECT
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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;
AND CORRECT ANSWERS
HCF Investigator Assumptions - CORRECT 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
Fraud, by it's very nature, is decptive. - CORRECT 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 - CORRECT 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 - CORRECT ANSWER The process of
uncovering potential fraud waste and abuse utilizing human and technical resources and
techniques
Anatomy of an investigation - 2) Assessment - CORRECT ANSWER The primary
objective of the assessment phase is to establish PREDICATION for the continued
investigation
Predication - CORRECT ANSWER to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - CORRECT
ANSWER Devoloping an investigative plan to identify and gather evidence to support
the statuatory elements to prove
Anatomy of an investigation - 4) Case Investigation - CORRECT ANSWER The
process of utilizing legal and appropriate techniques to prove or disprove the allegations
Antomy of an investigation - 5) Report Writing - CORRECT ANSWER The process of
documenting the investigative tasks in a final comprehensive investigative report.
Anatomy of an investigation - 6) Determination of action - CORRECT
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 - CORRECT
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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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 - CORRECT 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;
