AHFI Examination Prep Course
Comprehensive Questions
(Frequently Tested) and Complete
Solutions Graded A+
Professional Academic Assistance Services
Services Offered
• Proctored Exam Assistance
• Online Class Management (Full Course Support)
• Exam Preparation & Study Materials
• Assignments and Coursework Support
• Essay and Research Paper Writing
• Discussion Posts & Responses
• Editing and Proofreading
• Confidential Academic Consultation
Contact Information
Email:
WhatsApp link: https://wa.me/254704846336
Fast Response | Confidential | Reliable Academic Support
Helping Students Achieve Academic Excellence
HCF Investigator Assumptions - Answer: *General knowledge of the
Health care Delivery System
*Health plan policy and procedures relative to the delivery of services
,*Able to identify Red Flags, behaviors & indicators of health care fraud
schemes
Know applicable federal & state laws related to health care fraud
*Law enforcement & regulatory agencies that have oversight
responsibilities for HCF
*Local & regional investigative groups that have similar interests
Fraud, by it's very nature, is decptive. - Answer: As such, nobody really
knows what the impact and cost of fraud is. However there are some
common industry estimates
Conservative US Healthcare spending in 2015 was $3.2Trillion
Conservative estimate of fraud is 3-5% (means tens of billions of dollars
each year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between
5% and 10%)
,Anatomy of an investigation - Answer: Each fraud case is unique,
however, under the surface of the specific schemes, all HCF
investigatons have a common structure, or process.
Anatomy of an investigation - 1) Detection - Answer: The process of
uncovering potential fraud waste and abuse utilizing human and
technical resources and techniques
Anatomy of an investigation - 2) Assessment - Answer: The primary
objective of the assessment phase is to establish PREDICATION for the
continued investigation
Predication - Answer: to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Answer:
Devoloping an investigative plan to identify and gather evidence to
support the statuatory elements to prove
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
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)
Comprehensive Questions
(Frequently Tested) and Complete
Solutions Graded A+
Professional Academic Assistance Services
Services Offered
• Proctored Exam Assistance
• Online Class Management (Full Course Support)
• Exam Preparation & Study Materials
• Assignments and Coursework Support
• Essay and Research Paper Writing
• Discussion Posts & Responses
• Editing and Proofreading
• Confidential Academic Consultation
Contact Information
Email:
WhatsApp link: https://wa.me/254704846336
Fast Response | Confidential | Reliable Academic Support
Helping Students Achieve Academic Excellence
HCF Investigator Assumptions - Answer: *General knowledge of the
Health care Delivery System
*Health plan policy and procedures relative to the delivery of services
,*Able to identify Red Flags, behaviors & indicators of health care fraud
schemes
Know applicable federal & state laws related to health care fraud
*Law enforcement & regulatory agencies that have oversight
responsibilities for HCF
*Local & regional investigative groups that have similar interests
Fraud, by it's very nature, is decptive. - Answer: As such, nobody really
knows what the impact and cost of fraud is. However there are some
common industry estimates
Conservative US Healthcare spending in 2015 was $3.2Trillion
Conservative estimate of fraud is 3-5% (means tens of billions of dollars
each year)
Estimate of $96 billion -> $320 Billion / year (if we estimate between
5% and 10%)
,Anatomy of an investigation - Answer: Each fraud case is unique,
however, under the surface of the specific schemes, all HCF
investigatons have a common structure, or process.
Anatomy of an investigation - 1) Detection - Answer: The process of
uncovering potential fraud waste and abuse utilizing human and
technical resources and techniques
Anatomy of an investigation - 2) Assessment - Answer: The primary
objective of the assessment phase is to establish PREDICATION for the
continued investigation
Predication - Answer: to proclaim; declare; assert
Anatomy of an Investigation - 3) Investigative Strategy - Answer:
Devoloping an investigative plan to identify and gather evidence to
support the statuatory elements to prove
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
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)
