AHFI EXAM PREP COURSE STUDY GUIDE
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
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
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
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)
Prescribed by a doctor when the patient is homebound and needs intermittent skilled
care.
Watch for MDs who write Rx for home health care when there is no real medical
necessity;
Unlicensed workers rendering care;
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
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
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
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)
Prescribed by a doctor when the patient is homebound and needs intermittent skilled
care.
Watch for MDs who write Rx for home health care when there is no real medical
necessity;
Unlicensed workers rendering care;
