100+ Free HCAFA Practice Questions

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How does CMS typically distinguish "waste" from fraud and abuse?

Waste reflects overutilization or misuse of resources without intent, often through inefficiency

Waste includes only deliberate billing for services not rendered

Waste is identical to fraud and requires criminal intent

Waste is only a Medicaid concept

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2026 Statistics

Key Facts: HCAFA Exam

Courses required for HCAFA

AHIP HCAFA designation page

$205-$250

Per-course price

AHIP anti-fraud course pricing

90-180 days

Completion window per course

AHIP anti-fraud courses page

FCA damages multiplier

31 U.S.C. § 3729

60 days

Overpayment return deadline

42 U.S.C. § 1320a-7k(d)

Self-paced

Online format

AHIP Insurance Education

HCAFA is AHIP's self-paced online anti-fraud designation requiring Fraud Part I, Fraud Part II, and one elective fraud webinar. Each AHIP course costs $205 for AHIP members or $250 for non-members and must be completed within a 90 to 180-day window. AHIP does not publish a HCAFA pass rate. The curriculum covers FWA definitions, the False Claims Act, Anti-Kickback Statute, Stark Law, HIPAA criminal provisions, EKRA, NAIC Model #680 state fraud requirements, provider and member fraud schemes, pharmacy fraud, SIU operations, data analytics, case investigation, and regulatory reporting.

Sample HCAFA Practice Questions

Try these sample questions to test your HCAFA exam readiness. Each question includes a detailed explanation. Start the interactive quiz above for the full 100+ question experience with AI tutoring.

1Which element distinguishes health care fraud from waste or abuse under the NHCAA definition?

A.Intentional deception or misrepresentation knowing it could result in an unauthorized benefit

B.Any billing error that causes financial loss to a payer

C.Provision of services that are medically unnecessary but billed correctly

D.Overutilization of services without any misrepresentation

Explanation: NHCAA defines health care fraud as an intentional deception or misrepresentation that the individual or entity makes knowing the misrepresentation could result in some unauthorized benefit. The defining element is intent (mens rea). Waste typically involves overutilization without intent, and abuse involves practices inconsistent with sound medical or business practice but without proven intent to deceive.

2Which federal statute imposes treble damages plus per-claim civil penalties on persons who knowingly submit false claims to the government?

A.False Claims Act, 31 U.S.C. § 3729

B.Anti-Kickback Statute, 42 U.S.C. § 1320a-7b

C.Stark Law, 42 U.S.C. § 1395nn

D.HIPAA criminal provisions, 42 U.S.C. § 1320d-6

Explanation: The civil False Claims Act, 31 U.S.C. § 3729, makes anyone who knowingly submits or causes the submission of a false claim to the federal government liable for three times the government's damages plus a per-claim civil penalty (adjusted annually for inflation under 28 C.F.R. § 85.5).

3A whistleblower who files a False Claims Act lawsuit on behalf of the United States is known as what?

A.Qui tam relator under 31 U.S.C. § 3730(b)

B.Special inspector under 31 U.S.C. § 3729(c)

C.Compliance complainant under 42 U.S.C. § 1320c

D.Civil monetary informant under 42 U.S.C. § 1320a-7a

Explanation: Section 3730(b) of the False Claims Act authorizes a private person (relator) to bring a qui tam civil action in the name of the government. If the case succeeds, the relator may receive 15-25% of the recovery if the government intervenes, or 25-30% if it does not.

4Under the federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b), what mental state is required for criminal liability?

A.Knowingly and willfully offering, paying, soliciting, or receiving remuneration to induce referrals

B.Strict liability — no intent required

C.Negligently approving payment for a referral

D.Recklessly disregarding a Stark Law exception

Explanation: AKS is a criminal statute that prohibits anyone from knowingly and willfully offering, paying, soliciting, or receiving any remuneration to induce or reward referrals of items or services reimbursable by a federal health care program. The Patient Protection and Affordable Care Act amended AKS so that a person need not have actual knowledge of the statute or specific intent to violate it.

5Which statement best describes the Stark Law (42 U.S.C. § 1395nn)?

A.A strict-liability physician self-referral law prohibiting referrals for designated health services to entities with which the physician has a financial relationship, absent an exception

B.A criminal statute requiring proof of intent to induce referrals

C.A whistleblower retaliation statute applicable only to Medicare Advantage plans

D.A Civil Monetary Penalty provision targeting EMTALA violations

Explanation: The Stark Law is a strict-liability civil statute that bars a physician from referring Medicare patients for designated health services (DHS) to an entity with which the physician (or immediate family) has a financial relationship, unless an exception applies. Intent to induce referrals is not required.

6Which of the following is a Stark Law designated health service (DHS)?

A.Clinical laboratory services

B.General nursing assessment at a private home

C.Vision exams performed at retail kiosks

D.Routine dental cleanings

Explanation: DHS categories under Stark include clinical laboratory services, physical and occupational therapy, radiology and imaging, radiation therapy, DME and supplies, parenteral and enteral nutrients, prosthetics and orthotics, home health services, outpatient prescription drugs, and inpatient and outpatient hospital services.

7Under 42 U.S.C. § 1320a-7 (the Exclusion Statute), which conviction triggers a MANDATORY exclusion from participation in federal health care programs?

A.Conviction of a criminal offense related to delivery of an item or service under Medicare or Medicaid

B.Civil settlement of an alleged billing error

C.Receipt of a warning letter from a state insurance commissioner

D.Suspension of a state professional license for one week

Explanation: Section 1320a-7(a) mandates exclusion of any individual or entity convicted of a criminal offense related to delivery of items or services under Medicare or Medicaid, patient abuse or neglect, felony health care fraud, or a felony controlled substance offense. OIG maintains the List of Excluded Individuals/Entities (LEIE).

8Which OIG-maintained tool must health plans screen against to confirm a provider is eligible to receive federal payments?

A.List of Excluded Individuals/Entities (LEIE)

B.PECOS provider enrollment file

C.NPPES National Provider Identifier registry

D.SAM.gov entity registration

Explanation: OIG's LEIE is the official source for verifying that a provider, vendor, or employee is not excluded from federal health care programs under § 1320a-7. Payments for items or services furnished by an excluded person can trigger CMPs.

9The Civil Monetary Penalties Law (42 U.S.C. § 1320a-7a) authorizes OIG to impose penalties for what type of conduct?

A.Presenting a claim the person knows or should know is for an item or service not provided as claimed or that is false or fraudulent

B.Filing a tax return with an arithmetic error

C.Issuing a corporate press release without a disclaimer

D.Filing a state insurance form one day late

Explanation: The CMPL covers a broad range of misconduct including presenting false claims, providing remuneration to beneficiaries to influence selection of a provider, employing an excluded individual, and patient dumping. The scienter standard is "knows or should know," lower than the FCA's "knowing" standard.

10The HIPAA criminal provision at 42 U.S.C. § 1320d-6 punishes which conduct?

A.Knowingly using or causing the disclosure of individually identifiable health information in violation of the statute

B.Failing to file a Medicare cost report

C.Refusing to credential a provider

D.Submitting a duplicate claim by mistake

Explanation: Section 1320d-6 imposes graduated criminal penalties (up to ten years and $250,000 if done with intent to sell, transfer, or use PHI for commercial advantage, personal gain, or malicious harm) for the wrongful use or disclosure of individually identifiable health information.

About the HCAFA Exam

HCAFA is AHIP's entry-level designation for health care anti-fraud professionals. It requires completion of Fraud Part I (Introduction), Fraud Part II (Key Products), and one elective fraud-focused webinar. The curriculum covers definitions of fraud, waste, and abuse, federal statutes (FCA, AKS, Stark, HIPAA, EKRA, exclusion, CMP), state insurance fraud laws (NAIC Model #680), provider and member fraud schemes, pharmacy fraud, SIU operations, data analytics, case investigation, and regulatory reporting to OIG, MFCUs, UPICs, and state fraud bureaus.

Questions

100 scored questions

Time Limit

Self-paced, 90-180 days per course

Passing Score

Per AHIP course policy

Exam Fee

$205 member / $250 non-member per course (America's Health Insurance Plans (AHIP))

HCAFA Exam Content Outline

25%

Fraud Fundamentals (Fraud Part I)

Definitions of fraud, waste, and abuse; intent requirement; investigative methods; legal, regulatory, and compliance landscape across the health insurance industry

20%

Federal Anti-Fraud Laws

False Claims Act (31 U.S.C. § 3729), Anti-Kickback Statute (42 U.S.C. § 1320a-7b), Stark Law (42 U.S.C. § 1395nn), CMPL (42 U.S.C. § 1320a-7a), HIPAA criminal provisions, Exclusion Statute, EKRA (18 U.S.C. § 220), and 60-day overpayment rule

State Insurance Fraud Laws

NAIC Insurance Fraud Prevention Model Act (#680), SIU plans, mandatory state fraud-bureau referrals, civil immunity for good-faith reporting

15%

Provider Fraud Schemes

Upcoding, unbundling, services not rendered, DME phantom billing, telemedicine fraud, genetic-testing schemes, hospice and home health fraud, Two-Midnight Rule abuse

Member Fraud Schemes

Insurance-card sharing, dependent eligibility fraud, doctor shopping, medical identity theft

Pharmacy Fraud (Fraud Part II)

Billing for prescriptions not dispensed, drug diversion, PBM spread pricing, pharmacy upcoding via DAW codes, and pill-mill detection

SIU Operations

SIU role and plans, tip intake, peer comparison, NHCAA SIRIS sharing, clinical review, conflict-of-interest policies, cost avoidance, and SIU metrics

Data Analytics & Detection

Benford's Law, link analysis, geo-mapping, impossible-day checks, acquisition reconciliation, and converting findings into pre-pay claim edits

Case Investigation

Interview ethics, chain of custody, records requests, whistleblower protection, evidence admissibility, and confirmation-bias mitigation

Regulatory Reporting & Programs

HHS-OIG, UPIC, MFCU, HCFAC, HEAT, RAC, CMS SRDP, OIG SDP, Corporate Integrity Agreements, and OIG Compliance Program Guidance

How to Pass the HCAFA Exam

What You Need to Know

Passing score: Per AHIP course policy
Exam length: 100 questions
Time limit: Self-paced, 90-180 days per course
Exam fee: $205 member / $250 non-member per course

Keys to Passing

Complete 500+ practice questions
Score 80%+ consistently before scheduling
Focus on highest-weighted sections
Use our AI tutor for tough concepts

HCAFA Study Tips from Top Performers

1Memorize the elements of the False Claims Act, Anti-Kickback Statute, Stark Law, CMPL, and HIPAA criminal provisions, including the exact scienter required by each

2Drill the differences between fraud, waste, and abuse using CMS and NHCAA definitions, and practice categorizing real-world scenarios

3Build a personal cheat sheet of provider schemes (upcoding, unbundling, ghost billing, DME, telemedicine, hospice, home health) with one detection signal for each

4Study NAIC Model #680 and how state SIU plans, referral timelines, and civil-immunity provisions interact with federal statutes

5Practice analytic intuition: Benford's Law, peer comparison, geo-mapping, link analysis, and reconciling drug-acquisition data to billed units

Frequently Asked Questions

What is the AHIP HCAFA designation?

HCAFA stands for Health Care Anti-Fraud Associate, an entry-level professional designation awarded by AHIP. Earning HCAFA demonstrates a broad understanding of the types of health care fraud, how schemes work, and how insurers, regulators, and law enforcement combat them. It is widely used by SIU investigators, claims auditors, and compliance staff in commercial and Medicare/Medicaid plans.

What courses do I need for HCAFA?

AHIP requires two core courses — Fraud Part I (Introduction) and Fraud Part II (Key Products) — plus one elective from AHIP's catalog of on-demand fraud webinars. Fraud Part I focuses on detection, deterrence, and the legal and regulatory framework. Fraud Part II covers product-specific schemes in disability, LTC, dental, pharmaceutical, supplemental, and Medigap insurance.

How much does HCAFA cost in 2026?

Each AHIP anti-fraud course is $205 for AHIP members and $250 for non-members. With two required courses plus one elective webinar, the typical total cost is approximately $615-$750 depending on AHIP membership status. Always confirm current pricing on AHIP's anti-fraud designations page before enrolling.

How long do I have to complete an AHIP fraud course?

AHIP grants students 90 to 180 days to complete each purchased course. The window applies per course, so candidates working through Fraud Part I, Fraud Part II, and an elective webinar can pace themselves over several months while completing the full HCAFA curriculum.

Is HCAFA the same as the AHIP Medicare FWA certification?

No. The annual Medicare + Fraud, Waste, and Abuse Training is a separate AHIP product required for many Medicare-selling agents and contains a 50-question test scored at a 90% pass threshold. HCAFA is a multi-course professional designation focused on the broader anti-fraud field and is not interchangeable with the agent-facing Medicare FWA exam.

Will HCAFA prepare me for the NHCAA AHFI credential?

HCAFA is a strong foundation but is not a substitute for NHCAA's Accredited Health Care Fraud Investigator credential. AHFI requires at least five years of qualifying experience in health care fraud detection and investigation, NHCAA membership through an eligible employer, and a separate AHFI exam. Many candidates earn HCAFA early in their career and pursue AHFI after they accrue the required investigation experience.

Who should consider earning HCAFA?

HCAFA is targeted at SIU investigators, claims auditors, compliance and program-integrity staff, provider-relations specialists, and other professionals at health plans, PBMs, third-party administrators, and government program integrity contractors. It is also valuable for clinicians moving into utilization-review or program-integrity roles.