AHFI (Accredited Health Care Fraud Investigator)
Examination - Actual Test
EXAM COVERAGE
AHFI (Accredited Health Care Fraud Investigator)
Examination - Actual Test
Note: The AHFI® exam is administered by the National
Health Care Anti‑Fraud Association (NHCAA) and
measures the core skills of a health care fraud investigator
based on real investigative experience, not rote
,memorization.
1. U.S. Health Care System
Structure and key components of the U.S. health care
delivery system
Roles of public and private payers
Health care financing fundamentals
2. Business & Operations of Health Insurance
How health insurance plans operate
Claims adjudication process
Provider reimbursement systems
3. Fraud, Waste & Abuse (FWA) Fundamentals
Common health care fraud schemes and red flags
Differences between fraud, waste, and abuse
Identification and prevention strategies
,4. Legal & Regulatory Framework
Anti‑Kickback Statute principles and prohibited practices
Stark Law basics and exceptions
False Claims Act overview
HIPAA privacy & security regulations (based on typical
prep materials and past exam content)
5. Investigation Process & Techniques
Detection methods and case predication
Data analysis and investigative planning
Evidence collection, chain of custody, interviewing
techniques
Documentation and case reporting procedures
(commonly emphasized in prep questions)
6. Resolution & Reporting
, Case closure standards and outcome documentation
Reporting requirements (internal and external)
Liaison with legal counsel and law enforcement
Exam Format Highlights (practice insights)
Multiple‑choice questions
Scenario‑based questions requiring analytical reasoning
(Practice resources suggest ~150+ questions covering the
above domains)
Key Focus Areas
Practical application of investigation methods
Recognizing fraud schemes and applying legal standards
Interpreting operational and regulatory requirements
Examination - Actual Test
EXAM COVERAGE
AHFI (Accredited Health Care Fraud Investigator)
Examination - Actual Test
Note: The AHFI® exam is administered by the National
Health Care Anti‑Fraud Association (NHCAA) and
measures the core skills of a health care fraud investigator
based on real investigative experience, not rote
,memorization.
1. U.S. Health Care System
Structure and key components of the U.S. health care
delivery system
Roles of public and private payers
Health care financing fundamentals
2. Business & Operations of Health Insurance
How health insurance plans operate
Claims adjudication process
Provider reimbursement systems
3. Fraud, Waste & Abuse (FWA) Fundamentals
Common health care fraud schemes and red flags
Differences between fraud, waste, and abuse
Identification and prevention strategies
,4. Legal & Regulatory Framework
Anti‑Kickback Statute principles and prohibited practices
Stark Law basics and exceptions
False Claims Act overview
HIPAA privacy & security regulations (based on typical
prep materials and past exam content)
5. Investigation Process & Techniques
Detection methods and case predication
Data analysis and investigative planning
Evidence collection, chain of custody, interviewing
techniques
Documentation and case reporting procedures
(commonly emphasized in prep questions)
6. Resolution & Reporting
, Case closure standards and outcome documentation
Reporting requirements (internal and external)
Liaison with legal counsel and law enforcement
Exam Format Highlights (practice insights)
Multiple‑choice questions
Scenario‑based questions requiring analytical reasoning
(Practice resources suggest ~150+ questions covering the
above domains)
Key Focus Areas
Practical application of investigation methods
Recognizing fraud schemes and applying legal standards
Interpreting operational and regulatory requirements
