Free AHFI Practice Questions

Question 1

Attendance logs show one therapist leading a group session. Separate claims describe each participant's treatment during that same period as individual psychotherapy. No one-to-one encounters occurred. The payer's individual-service code requires one-to-one treatment and pays more than its group-service code. The practice produces valid authorizations for individual therapy. Which audit finding reconciles the service evidence with the claims?

Accepted Answer

The claims misrepresent documented group care as higher-paid individual treatment.

Answer

The overlap establishes phantom treatment, so the records support no clinical service at all.

Answer

The authorizations validate individual billing despite the treatment having occurred in a group.

Answer

The separate patient records justify individual billing if each records the full session time.

Question 2

One commercial claim has this settled payment history: an original payment of $1,200; a $1,200 reversal fully offset against later payments; and an $840 replacement payment. Record review establishes $600 as correctly payable. No further refunds or adjustments apply. What overpayment remains?

Accepted Answer

$240

Answer

$600

Answer

$840

Answer

$1,440

Question 3

The surveillance log for a Medicare home-health beneficiary reads: 'Attended a short religious service with daughter; used walker and needed help getting into the car.' Clinical records substantiate that leaving home requires considerable effort, that she normally cannot do so without assistance, and that she needs intermittent skilled wound care. All other eligibility requirements are met. Does this observation support a denial for lack of homebound status?

Accepted Answer

No; this outing is compatible with her documented homebound limitations.

Answer

Yes; suspend payments until she restricts her outings to medical visits.

Answer

Yes; nonmedical outings disqualify her on the dates she leaves home.

Answer

No; a skilled-care order establishes homebound status regardless of her ability to leave.

Question 4

'I never opened a chart, so I could not have known a claim was false.' A billing director offers this explanation after repeatedly receiving specific warnings that software was adding unsupported units to Medicare claims. She had instructed staff not to examine the affected claims and left the setting active. How does the civil False Claims Act treat her decision to avoid reviewing the evidence?

Accepted Answer

Deliberate ignorance can meet the knowledge requirement without specific intent to defraud.

Answer

Knowledge requires an admission that she intended to defraud Medicare.

Answer

The software vendor's knowledge must be established before hers can be evaluated.

Answer

Knowledge requires her personal review of a particular false claim.

Question 5

An SIU validates an alert against an independent review of all 1,000 claims in a test population.
Flagged: 30 claims with unsupported payments; 70 without.
Not flagged: 20 claims with unsupported payments; 880 without.
The manager wants the confirmation rate among flagged claims to plan review capacity. Which interpretation answers that question?

Accepted Answer

30%; about 70 reviews per 100 alerts would not confirm an unsupported payment.

Answer

60%; about 40 reviews per 100 alerts would not confirm an unsupported payment.

Answer

91%; about 9 reviews per 100 alerts would not confirm an unsupported payment.

Answer

93%; about 7 reviews per 100 alerts would not confirm an unsupported payment.

Question 6

An excess-units denial cites a Medicare medically unlikely edit with adjudication indicator 3. Records substantiate that the full quantity was furnished, correctly coded, and medically necessary; no separate coverage restriction has been found. The practice asks how to pursue payment for those units. The appropriate route is to:

Accepted Answer

Request reopening or redetermination and submit the supporting medical records.

Answer

Reduce the billed units to the edit value and abandon the remainder.

Answer

Split the units across claim lines using distinct-service modifiers.

Answer

Treat the edit as an absolute daily limit and accept the denial.

Question 7

An investigator reviews a proposed recovery of therapy payments for a 16-year-old Medicaid beneficiary with a developmental disability. The sole reason given is that adults do not receive this benefit under the state plan. State review confirms that the service is medically necessary to ameliorate the child's condition, falls within a federally Medicaid-coverable category, and meets all other payment requirements. Which recommendation is warranted?

Accepted Answer

Withdraw the proposed recovery because EPSDT applies to this covered treatment.

Answer

Sustain the recovery because treatment benefits are limited to the adult state-plan list.

Answer

Defer the recovery until the state adds the therapy to its adult benefit package.

Answer

Recover payments for continuing treatment while allowing the screening and diagnostic visits.

Question 8

An EHR audit-log overwrite is scheduled for midnight. At 3 p.m., the investigator obtains authorization for the records custodian to export logs relevant to suspected backdating. Physician interviews are set for the next morning. Choose the action that protects the evidence needed to reconstruct the changes.

Accepted Answer

Preserve the native logs and metadata, documenting acquisition and integrity checks.

Answer

Ask the physicians to sign statements verifying the current notes, then collect the logs.

Answer

Interview the billing manager before deciding whether to request an export.

Answer

Capture the visible chart screens instead of exporting the audit logs.

Question 9

A laboratory pays a physician's practice a 'processing fee' for each Medicare specimen referred. The practice performs no collection, processing, or transport work for that fee. Emails describe the payments as rewards for sending patients to the laboratory. Review confirms that the tests were necessary, performed, and correctly coded. The laboratory argues that these clinical findings resolve the concern. Which response addresses the unresolved issue?

Accepted Answer

Necessary, correctly billed tests do not resolve whether the payments rewarded referrals.

Answer

The laboratory's completed testing substantiates the processing services purchased from the practice.

Answer

The inquiry requires evidence that the fee increased Medicare's payment per test.

Answer

The inquiry requires evidence that patients were denied their choice of laboratory.

Question 10

'The edit has modifier indicator 1, so modifier 59 makes both codes payable,' a surgeon tells an investigator. The operative report describes a component procedure integral to the primary procedure at the same site during one encounter. No distinct service is documented. Under Medicare NCCI rules, what should the investigator conclude about separate payment for the component?

Accepted Answer

It is unsupported because an integral component is not a distinct service.

Answer

It is supported because the operative report proves the component was performed.

Answer

It is supported because indicator 1 permits the use of modifier 59.

Answer

It is unsupported because indicator 1 prohibits any modifier from bypassing the edit.

Free AHFI Practice Questions

Domain 1: The Nature and Scope of The U.S. Health Care System

Question 1

Question 2

Domain 2: The Business and Operations of the Health Care Insurance System

Question 3

Question 4

Question 5

Domain 3: Prevention, Identification and Detection of FWA

Question 6

Question 7

Question 8

Domain 4: Investigative, Resolution and Reporting Process

Question 9

Question 10

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