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AHFI (Accredited Health Care Fraud Investigator)
Examination – ACTUAL VERIFIED EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS LATEST
UPDATE THIS YEAR||NEWEST EXAM!!!
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
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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:
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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.
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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
AHFI (Accredited Health Care Fraud Investigator)
Examination – ACTUAL VERIFIED EXAM COMPLETE
QUESTIONS AND VERIFIED SOLUTIONS LATEST
UPDATE THIS YEAR||NEWEST EXAM!!!
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
,2|Page
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:
,3|Page
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.
, 4|Page
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
