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AHFI (Accredited Health Care Fraud Investigator) Examination
– ACTUAL EXAM COMPLETE QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE THIS YEAR
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
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• 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
1. The conservative estimate of healthcare fraud in the U.S. is approximately:
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A. 1–2%
B. 3–5%
C. 8–12%
D. 15–20%
Answer: B
Rationale: Industry estimates place healthcare fraud at approximately 3–5% of total healthcare
spending, equating to tens of billions annually.
2. The first stage in the anatomy of a health care fraud investigation is:
A. Assessment
B. Case Investigation
C. Detection
D. Report Writing
Answer: C
Rationale: Detection is the initial stage where potential fraud, waste, and abuse are identified
using technical and human resources.
3. The primary objective of the assessment phase is to:
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A. Interview witnesses
B. Draft a final report
C. Establish predication
D. Refer to law enforcement
Answer: C
Rationale: Assessment focuses on establishing predication—legal grounds to continue the
investigation.
4. Predication refers to:
A. Statistical analysis
B. Asserting or declaring grounds for investigation
C. Proving guilt
D. Conducting interviews
Answer: B
Rationale: Predication means declaring or asserting sufficient basis to investigate further.
5. Which stage involves developing a plan to prove statutory elements?
A. Detection
B. Assessment
AHFI (Accredited Health Care Fraud Investigator) Examination
– ACTUAL EXAM COMPLETE QUESTIONS AND VERIFIED
SOLUTIONS LATEST UPDATE THIS YEAR
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
,Page 2 of 83
• 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
1. The conservative estimate of healthcare fraud in the U.S. is approximately:
,Page 3 of 83
A. 1–2%
B. 3–5%
C. 8–12%
D. 15–20%
Answer: B
Rationale: Industry estimates place healthcare fraud at approximately 3–5% of total healthcare
spending, equating to tens of billions annually.
2. The first stage in the anatomy of a health care fraud investigation is:
A. Assessment
B. Case Investigation
C. Detection
D. Report Writing
Answer: C
Rationale: Detection is the initial stage where potential fraud, waste, and abuse are identified
using technical and human resources.
3. The primary objective of the assessment phase is to:
, Page 4 of 83
A. Interview witnesses
B. Draft a final report
C. Establish predication
D. Refer to law enforcement
Answer: C
Rationale: Assessment focuses on establishing predication—legal grounds to continue the
investigation.
4. Predication refers to:
A. Statistical analysis
B. Asserting or declaring grounds for investigation
C. Proving guilt
D. Conducting interviews
Answer: B
Rationale: Predication means declaring or asserting sufficient basis to investigate further.
5. Which stage involves developing a plan to prove statutory elements?
A. Detection
B. Assessment
