AHFI (ACCREDITED HEALTH CARE FRAUD
INVESTIGATOR) EXAMINATION COMPLETE
PRACTICE EXAM – 300 QUESTIONS WITH VERIFIED
ANSWERS
SECTION 1: U.S. HEALTH CARE SYSTEM (Questions 1–50)
1. The conservative estimate of healthcare fraud in the U.S. is approximately:
A) $5-10 billion annually
B) $50-75 billion annually
C) $96-320 billion annually (3-10% of total spending)
D) $500 billion annually
✅ Answer: C
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
✅ Answer: B
3. Which of the following is a public payer in the U.S. health care system?
A) Blue Cross Blue Shield
B) Medicare
C) Aetna
D) UnitedHealthcare
✅ Answer: B
4. The primary source of funding for Medicare Part A (Hospital Insurance) is:
A) General tax revenues
B) Payroll taxes (FICA)
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, C) Monthly premiums from beneficiaries
D) State appropriations
✅ Answer: B
5. Medicare Part B covers:
A) Inpatient hospital stays
B) Physician services and outpatient care
C) Prescription drugs
D) Long-term nursing home care
✅ Answer: B
6. Medicaid is jointly funded by:
A) Federal and state governments
B) Private insurers and employers
C) Medicare and Social Security
D) Charitable organizations
✅ Answer: A
7. The Children’s Health Insurance Program (CHIP) is designed for:
A) Children in foster care
B) Children from low-income families who do not qualify for Medicaid
C) All children under age 18 regardless of income
D) Children with disabilities only
✅ Answer: B
8. What is the primary role of private health insurers in the U.S.?
A) To provide universal coverage
B) To offer supplemental and employer-sponsored coverage
C) To regulate public programs
D) To replace Medicare
✅ Answer: B
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,9. The term "third-party payer" refers to:
A) The patient receiving care
B) The provider delivering care
C) An entity that pays claims on behalf of the insured
D) The government regulator
✅ Answer: C
10. Which of the following is a characteristic of a fee-for-service (FFS) payment
model?
A) Providers receive a fixed amount per patient per month
B) Providers are paid for each service rendered
C) Providers share risk with the payer
D) Quality outcomes determine payment
✅ Answer: B
11. In a managed care model, the primary goal is to:
A) Maximize provider reimbursement
B) Control costs and coordinate care
C) Eliminate all denials
D) Increase hospital admissions
✅ Answer: B
12. Health Maintenance Organizations (HMOs) typically require:
A) Out-of-network coverage as standard
B) Referrals from a primary care physician for specialists
C) No prior authorizations
D) Unlimited choice of providers
✅ Answer: B
13. Preferred Provider Organizations (PPOs) differ from HMOs in that:
A) PPOs have lower premiums
B) PPOs allow out-of-network coverage at higher cost
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, C) PPOs require capitation
D) PPOs are only for Medicare
✅ Answer: B
14. The uninsured rate in the U.S. has been significantly reduced due to:
A) The Affordable Care Act (ACA)
B) The Balanced Budget Act
C) The HIPAA Privacy Rule
D) The Stark Law
✅ Answer: A
15. The ACA introduced Health Insurance Marketplaces to:
A) Replace Medicare
B) Allow individuals to compare and purchase private plans with subsidies
C) Eliminate employer-sponsored insurance
D) Mandate single-payer
✅ Answer: B
16. Which federal agency administers Medicare?
A) FDA
B) CMS (Centers for Medicare & Medicaid Services)
C) HHS Office of Inspector General
D) FBI
✅ Answer: B
17. Medicare Advantage (Part C) plans are:
A) Government-run fee-for-service
B) Private plans that contract with Medicare to provide Part A and B benefits
C) Supplemental drug coverage only
D) Medicaid replacement plans
✅ Answer: B
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INVESTIGATOR) EXAMINATION COMPLETE
PRACTICE EXAM – 300 QUESTIONS WITH VERIFIED
ANSWERS
SECTION 1: U.S. HEALTH CARE SYSTEM (Questions 1–50)
1. The conservative estimate of healthcare fraud in the U.S. is approximately:
A) $5-10 billion annually
B) $50-75 billion annually
C) $96-320 billion annually (3-10% of total spending)
D) $500 billion annually
✅ Answer: C
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
✅ Answer: B
3. Which of the following is a public payer in the U.S. health care system?
A) Blue Cross Blue Shield
B) Medicare
C) Aetna
D) UnitedHealthcare
✅ Answer: B
4. The primary source of funding for Medicare Part A (Hospital Insurance) is:
A) General tax revenues
B) Payroll taxes (FICA)
1
, C) Monthly premiums from beneficiaries
D) State appropriations
✅ Answer: B
5. Medicare Part B covers:
A) Inpatient hospital stays
B) Physician services and outpatient care
C) Prescription drugs
D) Long-term nursing home care
✅ Answer: B
6. Medicaid is jointly funded by:
A) Federal and state governments
B) Private insurers and employers
C) Medicare and Social Security
D) Charitable organizations
✅ Answer: A
7. The Children’s Health Insurance Program (CHIP) is designed for:
A) Children in foster care
B) Children from low-income families who do not qualify for Medicaid
C) All children under age 18 regardless of income
D) Children with disabilities only
✅ Answer: B
8. What is the primary role of private health insurers in the U.S.?
A) To provide universal coverage
B) To offer supplemental and employer-sponsored coverage
C) To regulate public programs
D) To replace Medicare
✅ Answer: B
2
,9. The term "third-party payer" refers to:
A) The patient receiving care
B) The provider delivering care
C) An entity that pays claims on behalf of the insured
D) The government regulator
✅ Answer: C
10. Which of the following is a characteristic of a fee-for-service (FFS) payment
model?
A) Providers receive a fixed amount per patient per month
B) Providers are paid for each service rendered
C) Providers share risk with the payer
D) Quality outcomes determine payment
✅ Answer: B
11. In a managed care model, the primary goal is to:
A) Maximize provider reimbursement
B) Control costs and coordinate care
C) Eliminate all denials
D) Increase hospital admissions
✅ Answer: B
12. Health Maintenance Organizations (HMOs) typically require:
A) Out-of-network coverage as standard
B) Referrals from a primary care physician for specialists
C) No prior authorizations
D) Unlimited choice of providers
✅ Answer: B
13. Preferred Provider Organizations (PPOs) differ from HMOs in that:
A) PPOs have lower premiums
B) PPOs allow out-of-network coverage at higher cost
3
, C) PPOs require capitation
D) PPOs are only for Medicare
✅ Answer: B
14. The uninsured rate in the U.S. has been significantly reduced due to:
A) The Affordable Care Act (ACA)
B) The Balanced Budget Act
C) The HIPAA Privacy Rule
D) The Stark Law
✅ Answer: A
15. The ACA introduced Health Insurance Marketplaces to:
A) Replace Medicare
B) Allow individuals to compare and purchase private plans with subsidies
C) Eliminate employer-sponsored insurance
D) Mandate single-payer
✅ Answer: B
16. Which federal agency administers Medicare?
A) FDA
B) CMS (Centers for Medicare & Medicaid Services)
C) HHS Office of Inspector General
D) FBI
✅ Answer: B
17. Medicare Advantage (Part C) plans are:
A) Government-run fee-for-service
B) Private plans that contract with Medicare to provide Part A and B benefits
C) Supplemental drug coverage only
D) Medicaid replacement plans
✅ Answer: B
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