AHFI (Accredited Health Care Fraud Investigator) Examination Complete 200 Questions with
Verified Answers and Detailed Explanations
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About the AHFI® Certification
The Accredited Health Care Fraud Investigator (AHFI®) designation is granted by the National
Health Care Anti-Fraud Association (NHCAA) to individuals who meet qualifications in
professional experience, specialized training, and demonstrated knowledge in detecting,
investigating, and prosecuting health care fraud .
Exam Focus: The exam is based on experience as a Special Investigations Unit (SIU) investigator
rather than memorization. It covers core competencies in fraud detection, investigation
methodology, legal frameworks, and regulatory compliance .
Renewal: Certification requires renewal every 3 years through continuing education .
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Section 1: Healthcare Fraud Fundamentals (Questions 1-30)
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Question 1
What is the estimated annual cost of healthcare fraud in the United States?
A. $5-10 billion
,B. $50-75 billion
C. $96-320 billion (3-10% of total spending)
D. $500 billion
Correct Answer: C
Rationale: Conservative US healthcare spending in 2015 was $3.2 trillion. With fraud estimates
ranging from 3-10%, the cost is between $96 billion and $320 billion annually .
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Question 2
According to the NHCAA, what is the primary reason fraud costs are difficult to quantify?
A. Lack of reporting mechanisms
B. Fraud is inherently deceptive by nature
C. Insufficient law enforcement resources
D. Providers refuse to cooperate
Correct Answer: B
Rationale: Fraud, by its very nature, is deceptive. As such, nobody really knows the true impact
and cost of fraud, making it inherently difficult to quantify .
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Question 3
,Which of the following is a core assumption of a healthcare fraud investigator?
A. Knowledge of health plan policy and procedures
B. Ability to identify red flags and fraud indicators
C. Knowledge of applicable federal and state laws
D. All of the above
Correct Answer: D
Rationale: A healthcare fraud investigator must have general knowledge of the healthcare
delivery system, health plan policies, ability to identify red flags, knowledge of applicable laws,
and awareness of regulatory agencies .
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Question 4
What is the first phase in the anatomy of a healthcare fraud investigation?
A. Assessment
B. Detection
C. Case Investigation
D. Report Writing
Correct Answer: B
Rationale: The anatomy of a healthcare fraud investigation begins with Detection—the process
of uncovering potential fraud, waste, and abuse utilizing human and technical resources .
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Question 5
What is the primary objective of the assessment phase in an investigation?
A. To interview witnesses
B. To establish predication for continued investigation
C. To write the final report
D. To arrest the subject
Correct Answer: B
Rationale: The primary objective of the assessment phase is to establish predication for the
continued investigation. Predication means to proclaim, declare, or assert—essentially,
establishing a factual basis to proceed .
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Question 6
What is predication in the context of healthcare fraud investigation?
A. The final determination of guilt
B. A factual basis to initiate or continue an investigation
C. The legal standard for conviction
D. A type of surveillance technique
Verified Answers and Detailed Explanations
---
About the AHFI® Certification
The Accredited Health Care Fraud Investigator (AHFI®) designation is granted by the National
Health Care Anti-Fraud Association (NHCAA) to individuals who meet qualifications in
professional experience, specialized training, and demonstrated knowledge in detecting,
investigating, and prosecuting health care fraud .
Exam Focus: The exam is based on experience as a Special Investigations Unit (SIU) investigator
rather than memorization. It covers core competencies in fraud detection, investigation
methodology, legal frameworks, and regulatory compliance .
Renewal: Certification requires renewal every 3 years through continuing education .
---
Section 1: Healthcare Fraud Fundamentals (Questions 1-30)
---
Question 1
What is the estimated annual cost of healthcare fraud in the United States?
A. $5-10 billion
,B. $50-75 billion
C. $96-320 billion (3-10% of total spending)
D. $500 billion
Correct Answer: C
Rationale: Conservative US healthcare spending in 2015 was $3.2 trillion. With fraud estimates
ranging from 3-10%, the cost is between $96 billion and $320 billion annually .
---
Question 2
According to the NHCAA, what is the primary reason fraud costs are difficult to quantify?
A. Lack of reporting mechanisms
B. Fraud is inherently deceptive by nature
C. Insufficient law enforcement resources
D. Providers refuse to cooperate
Correct Answer: B
Rationale: Fraud, by its very nature, is deceptive. As such, nobody really knows the true impact
and cost of fraud, making it inherently difficult to quantify .
---
Question 3
,Which of the following is a core assumption of a healthcare fraud investigator?
A. Knowledge of health plan policy and procedures
B. Ability to identify red flags and fraud indicators
C. Knowledge of applicable federal and state laws
D. All of the above
Correct Answer: D
Rationale: A healthcare fraud investigator must have general knowledge of the healthcare
delivery system, health plan policies, ability to identify red flags, knowledge of applicable laws,
and awareness of regulatory agencies .
---
Question 4
What is the first phase in the anatomy of a healthcare fraud investigation?
A. Assessment
B. Detection
C. Case Investigation
D. Report Writing
Correct Answer: B
Rationale: The anatomy of a healthcare fraud investigation begins with Detection—the process
of uncovering potential fraud, waste, and abuse utilizing human and technical resources .
, ---
Question 5
What is the primary objective of the assessment phase in an investigation?
A. To interview witnesses
B. To establish predication for continued investigation
C. To write the final report
D. To arrest the subject
Correct Answer: B
Rationale: The primary objective of the assessment phase is to establish predication for the
continued investigation. Predication means to proclaim, declare, or assert—essentially,
establishing a factual basis to proceed .
---
Question 6
What is predication in the context of healthcare fraud investigation?
A. The final determination of guilt
B. A factual basis to initiate or continue an investigation
C. The legal standard for conviction
D. A type of surveillance technique
