AHFI (ACCREDITED HEALTH CARE FRAUD INVESTIGATOR) ACTUAL
EXAM 2026/2027 AND STUDY GUIDE COMPLETE ACCURATE EXAM
APPROVED QUESTIONS WITH WELL ELABORATED ANSWERS WITH
DETAILED RATIONALES (VERIFIED SOLUTIONS) LATEST UPDATED
VERSION 2026 EDITION |GUARANTEED SUCCESS A+ |FULL REVISED
AHFI EXAM
1. Which federal law is primarily used to prosecute health care fraud
involving false statements in connection with federal health care
programs?
A) False Claims Act (FCA)
B) Anti-Kickback Statute (AKS)
C) Stark Law
D) Health Insurance Portability and Accountability Act (HIPAA)
CORRECT ANSWER: A
Rationale: The False Claims Act imposes liability on persons who
knowingly submit false claims to the government, including Medicare
and Medicaid. The AKS addresses kickbacks; Stark Law prohibits
physician self-referral; HIPAA governs privacy and security.
2. Under the Anti-Kickback Statute, intent is established if the
remuneration is offered in exchange for:
A) Medical necessity certification
B) Patient privacy compliance
C) Referral of federal health care program business
D) Electronic health record adoption
CORRECT ANSWER: C
Rationale: AKS prohibits knowingly offering or paying remuneration to
induce referrals for services payable by federal health care programs. It
is a one-way strict liability intent statute regarding referrals.
,3. Which element is NOT required to prove a violation of the False
Claims Act?
A) The defendant knowingly submitted a false claim
B) The claim was material to the government’s payment decision
C) The government suffered actual financial loss
D) The claim was presented to the government
CORRECT ANSWER: C
Rationale: FCA liability does not require actual government loss; even
an attempt to defraud or submitting a false statement to get a false claim
paid is sufficient.
4. A physician bills Medicare for a Level 5 office visit but only
performed a Level 2 service. This is an example of:
A) Unbundling
B) Upcoding
C) Multiple billing
D) Medically unnecessary service
CORRECT ANSWER: B
Rationale: Upcoding means billing for a higher-level procedure or
service than actually performed to increase reimbursement.
5. Which agency is the primary law enforcement arm for Medicare
fraud?
A) FBI
B) OIG (Office of Inspector General, HHS)
C) DEA
D) CMS
,CORRECT ANSWER: B
Rationale: HHS-OIG leads criminal, civil, and administrative
enforcement for federal health care fraud, working with DOJ and FBI.
6. The Stark Law prohibits:
A) Billing for non-covered services
B) Self-referral for designated health services under Medicare/Medicaid
when financial relationship exists
C) Prescribing controlled substances without DEA registration
D) Submitting claims without a valid NPI
CORRECT ANSWER: B
Rationale: Stark Law (physician self-referral law) bars physicians from
referring patients for certain DHS to entities with which they have a
financial relationship, absent an exception.
7. Which of the following is a "red flag" for health care fraud?
A) Consistent patient volumes month to month
B) Billing for services on weekends when clinic is closed
C) Use of certified EHR
D) Low denial rates
CORRECT ANSWER: B
Rationale: Billing for services during hours/days the facility is closed
suggests fabricated claims.
8. The "Safe Harbors" under the Anti-Kickback Statute provide:
A) Complete immunity for all financial arrangements
, B) Protections for certain business practices that would otherwise violate
AKS
C) Exclusive list of legal arrangements
D) Criminal penalties for compliance failures
CORRECT ANSWER: B
Rationale: Safe Harbors describe specific payment/business practices
that are not treated as criminal violations of AKS even if remuneration is
involved.
9. Qui tam provisions under the False Claims Act allow:
A) The government to sue without a plaintiff
B) A private citizen (relator) to sue on behalf of the government and
share in recovery
C) Only DOJ to initiate fraud cases
D) Defendants to avoid penalties if they self-report
CORRECT ANSWER: B
Rationale: Qui tam enables whistleblowers with inside knowledge to file
lawsuits for fraud against the government.
10. Which of the following is considered health care fraud under the
criminal code (18 USC 1347)?
A) Accidental coding error
B) Knowingly and willfully executing a scheme to defraud a health care
benefit program
C) Billing for a service later deemed medically unnecessary by a second
reviewer
D) Using an outdated CMS form
EXAM 2026/2027 AND STUDY GUIDE COMPLETE ACCURATE EXAM
APPROVED QUESTIONS WITH WELL ELABORATED ANSWERS WITH
DETAILED RATIONALES (VERIFIED SOLUTIONS) LATEST UPDATED
VERSION 2026 EDITION |GUARANTEED SUCCESS A+ |FULL REVISED
AHFI EXAM
1. Which federal law is primarily used to prosecute health care fraud
involving false statements in connection with federal health care
programs?
A) False Claims Act (FCA)
B) Anti-Kickback Statute (AKS)
C) Stark Law
D) Health Insurance Portability and Accountability Act (HIPAA)
CORRECT ANSWER: A
Rationale: The False Claims Act imposes liability on persons who
knowingly submit false claims to the government, including Medicare
and Medicaid. The AKS addresses kickbacks; Stark Law prohibits
physician self-referral; HIPAA governs privacy and security.
2. Under the Anti-Kickback Statute, intent is established if the
remuneration is offered in exchange for:
A) Medical necessity certification
B) Patient privacy compliance
C) Referral of federal health care program business
D) Electronic health record adoption
CORRECT ANSWER: C
Rationale: AKS prohibits knowingly offering or paying remuneration to
induce referrals for services payable by federal health care programs. It
is a one-way strict liability intent statute regarding referrals.
,3. Which element is NOT required to prove a violation of the False
Claims Act?
A) The defendant knowingly submitted a false claim
B) The claim was material to the government’s payment decision
C) The government suffered actual financial loss
D) The claim was presented to the government
CORRECT ANSWER: C
Rationale: FCA liability does not require actual government loss; even
an attempt to defraud or submitting a false statement to get a false claim
paid is sufficient.
4. A physician bills Medicare for a Level 5 office visit but only
performed a Level 2 service. This is an example of:
A) Unbundling
B) Upcoding
C) Multiple billing
D) Medically unnecessary service
CORRECT ANSWER: B
Rationale: Upcoding means billing for a higher-level procedure or
service than actually performed to increase reimbursement.
5. Which agency is the primary law enforcement arm for Medicare
fraud?
A) FBI
B) OIG (Office of Inspector General, HHS)
C) DEA
D) CMS
,CORRECT ANSWER: B
Rationale: HHS-OIG leads criminal, civil, and administrative
enforcement for federal health care fraud, working with DOJ and FBI.
6. The Stark Law prohibits:
A) Billing for non-covered services
B) Self-referral for designated health services under Medicare/Medicaid
when financial relationship exists
C) Prescribing controlled substances without DEA registration
D) Submitting claims without a valid NPI
CORRECT ANSWER: B
Rationale: Stark Law (physician self-referral law) bars physicians from
referring patients for certain DHS to entities with which they have a
financial relationship, absent an exception.
7. Which of the following is a "red flag" for health care fraud?
A) Consistent patient volumes month to month
B) Billing for services on weekends when clinic is closed
C) Use of certified EHR
D) Low denial rates
CORRECT ANSWER: B
Rationale: Billing for services during hours/days the facility is closed
suggests fabricated claims.
8. The "Safe Harbors" under the Anti-Kickback Statute provide:
A) Complete immunity for all financial arrangements
, B) Protections for certain business practices that would otherwise violate
AKS
C) Exclusive list of legal arrangements
D) Criminal penalties for compliance failures
CORRECT ANSWER: B
Rationale: Safe Harbors describe specific payment/business practices
that are not treated as criminal violations of AKS even if remuneration is
involved.
9. Qui tam provisions under the False Claims Act allow:
A) The government to sue without a plaintiff
B) A private citizen (relator) to sue on behalf of the government and
share in recovery
C) Only DOJ to initiate fraud cases
D) Defendants to avoid penalties if they self-report
CORRECT ANSWER: B
Rationale: Qui tam enables whistleblowers with inside knowledge to file
lawsuits for fraud against the government.
10. Which of the following is considered health care fraud under the
criminal code (18 USC 1347)?
A) Accidental coding error
B) Knowingly and willfully executing a scheme to defraud a health care
benefit program
C) Billing for a service later deemed medically unnecessary by a second
reviewer
D) Using an outdated CMS form
