AHFI Certification Study Guide

• Revised January 2023.
• This study guide assists in preparing for the AHFI certification, offering insights into healthcare fraud investigations.

NHCAA's Mission

• Protecting the public interest via increasing awareness and advancing the prevention, detection, and prosecution of health care fraud/abuse.
• Founded in 1985 by private health plans and federal/state government officials.

Important Terminology Notes

• Interchangeable terms in the guide: payer, health plan, and insurance company.
• Interchangeable terms: Member, insured, beneficiary, and subscriber
• This guide doesn't include enrollment statistics for business lines like Medicare, Medicaid, CHIP, etc.

Types of Health Insurance

• Individual health insurance is purchased independently, not through an employer.
• Premium payments cover plan benefits.
• Regulated by state law.
• Can be bought on or off the exchange.
• Termination can occur at any time per carrier rules, including failure to pay premiums, exceeding the age limit ,or acts of alleged fraud.
• Group health insurance protects a group of employees under one contract, offered through employers or associations.
• Groups qualify if formed for reasons beyond obtaining insurance.
• Employer-sponsored groups offer coverage to employees; eligible employees meet service requirements and work full-time.
• Group health insurance can be contributory (employees pay part of the premium) or noncontributory (employer pays the entire premium).
• Contributory plans require at least 75% participation of eligible employees; noncontributory plans require 100% inclusion.
• Group benefit administrators must inform the carrier of coverage terminations, often due to employment severance.

Coverage Decisions

• Fall into two categories: pre-enrollment and post-enrollment.
• Pre-enrollment decisions involve plan types and benefit levels chosen by the customer, potentially with broker assistance.
• Post-enrollment decisions differ by individual or group coverage.
• Individuals can change benefit levels or coverage anytime, following carrier rules.
• Benefit selection changes for groups are managed by the group benefit administrator, typically during open enrollment.

Insurance Plans: Key Concepts

• Coordination of Benefits (COB) prevents duplicate payments in Group Health plans when an individual has multiple coverages.
• COB establishes a primary plan to provide full benefits, limiting total claims paid to the total allowable medical expenses.
• Deductibles, also known as "self-insured retention," apply to claims (e.g., property, auto, health).
• Insurance companies deduct the deductible amount from the claims payment before remitting to the claimant.
• Coinsurance is the sharing of expenses between the insurance company and the insured, found in health and property policies.
• Many insurers use state-approved standardized forms rather than developing their own.

Agent/Broker Role

• Agents/brokers advise on plans based on the customer's situation, explaining details/eligibility.
• Brokers collect employee information for groups, which insurers use to assess risk and provide quotes.
• Agents represent health insurers, while brokers represent insurance purchasers, acting as intermediaries.
• Agents/brokers enroll customers in group or individual plans.

Enrollment Processes

• For group enrollment, the group signs a master contract while employees receive coverage certificates or summary plan descriptions.
• Employers have open enrollment periods (14–60 days) offering various options (paper, online, enrollers).
• Employees can enroll outside of open enrollment with qualifying events (newly hired, divorced, married, having a child).
• Individual market enrollments need active participation to complete product selection, demographics, and suitability forms.

Application Process

• Agents help groups find the best solution per needs/budget and gather key employee information/census.
• This information goes to the insurer underwriting for a quote.
• For individual coverage, brokers directly provide quotes using carrier tools/rate sheets.
• Customers complete coverage applications, potentially including medical reviews, online/paper/phone/in-person.
• Life insurance may require para-med exams.

Issue & Delivery

• Underwriting determines customer eligibility based on the plan.
• Policies go under the customer's name, prints being fulfilled electronically or physically.
• For group sales, the contract exists between the group and the carrier.
• Employees get a Certificate of Coverage and/or Summary Plan Description.

Types of Funding/Administration

• Fully-insured plans involve the employer paying premiums to an insurer, which covers employee groups for a fixed year.
• The insurer manages coverage.
• Self-insured plans involve employers operating Accident & Health plans to save on profit-margins insurers charge.
• Establishing their own health insurance program, the company pays claims out of own funds, becoming "at risk" for healthcare costs.
• Employers save money and pay claims directly.
• They may use a stop-loss clause sharing risk with an insurer and covering claims above a set amount ($1,000,000 for example).
• Self-insured plans are under Federal ERISA law, not state laws.
• To achieve savings, they instituting cost-containment mechanisms such as a PPO (Preferred Provider Organization).
• Benefits are structured for increased in-panel and decreased benefits for out-panel care.
• Enrollees receive financial incentive for in-panel care, but financial disincentive to receive out-of-panel care.
• Employers save from employees receiving in-panel care.
• Employees using out-of-panel providers file claims for reimbursement like traditional.

Third-Party Administrator (TPA)

• A TPA administers benefit plans for employers/insurers, but are not insurance companies.
• TPAs handle claims/risk management, but must abide laws that regulate the tasks that insurers are permitted to delegate to them, is set by state law.
• For coverage, contracts can exist between the TPA with the provider or with the employer.

Administrative Services Only (ASO)

• Companies can contract with existing insurers for ASO.
• The employer covers costs while the insurer provides benefit designs, claims processing, staff support, contracting providers for a fee.
• The insurer has claims determination/processing capacity, utilization review, pre-admission, etc.
• The insurer has staff for questions, using an ASO self-insurance put in place quickly, at a known fixed fee.

Payment Models

• Methods of paying for healthcare services include, but are not limited to: fee for service (FFS), capitation, bundled payments, and value-based reimbursement (VBR).

Fee for Service (FFS)

• Pays for specific services, rewarding quantity regardless of outcome.

Capitation

• Fixed amount paid in advance for care services.

Bundled Payments

• Comprehensive payment for all services in an episode of care.

Value Based Reimbursement (VBR)

• VBR is intended to encourage health care providers to deliver the best care at the lowest cost through financial rewards/punishments.

VBR Gain Share

• Allows the payer to share in the savings with the payer if average cost patient is less than a set target.

VBR Risk Share

• Providers may pay back a set amount above the target.
• Quality metrics must be met.

Types of Service Codes

• Current Procedural Terminology (CPT) - 8,000 codes owned by the American Medical Association describing services by physicians/others.
• Most outpatient services are report with this system.
• Health Care Procedural Coding System (HCPCS) Developed for Medicare/Medicaid, Blue Cross/Shield, reports procedures/supplies.
• 7,000 codes are used for quality tracking, surgery billing, and studies.
• International Classification of Diseases, 10th Edition, Clinically Modified (ICD-10-CM) 69,000 codes that describe diseases and conditions.
• International Classification of Diseases, 10th Edition, Procedural Coding System (ICD-10-PCS) Set of 130,000 codes used by hospitals for surgical procedures.
• Code on Dental Procedures and Nomenclature (CDT) Five-character codes by the American Dental Association for dental procedures.
• National Drug Codes (NDC) 10-13 alphanumeric codes to track drug packages.
• Modifiers Alphanumeric two-character codes used with CPT/HCPCS for clarity.
• Medical Severity Diagnosis Related Groups (MS-DRG) Reported by hospitals for reimbursement, based on ICD-10-CM, ICD-10-PCS.
• Ambulatory Payment Categories (APC) Support CMS's Hospital Outpatient Prospective Payment System (OPPS).

Claim Submission/Reimbursement

• Third-party payers (entities besides the patient or provider) manages healthcare expanses.
• Payers have multiple forms from public or private entities.
• With health insurance, doctor's offices/hospitals submit the claim directly to insurance with ICD-10 codes.
• The insurance agency provides payment to the facility, which sends remaining balances to patients.
• With supplemental insurance, customers file claims and can be asked the provide medical records.

Types of Insurance

• In a Preferred Provider Organization (PPO) plan, members can see any provider within their network without a referral.
• In Health Maintenance Organization (HMO) members must select a primary care to coordinate all health services.
• Exclusive Provider Organization (EPO) grants members network healthcare providers.
• High Deductible insurance requires members to meet the deductible and pay upfront before coverage takes effect.
• Money can be tax-deductible/saved in interest-earning accounts.
• Point of Service (POS) members designate a primary care physician, and can use out-of-network providers (with a copay or deductible).
• These policies cover costs excluded by a medical expense policy in policies of dental, disability and specified diseases.
• Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) applies to Group Health insurance.
• COBRA extends same group coverage via employee payments of premiums.
• COBRA requires employers to extend Group Health coverage to terminated/family memberees (with 20+ employees), up to 36 months after qualifying event. Qualifying events range from divorce, death, and termination (other than misconduct).

Limited/Supplemental Plans

• For Medicare Supplement insurance, supplemental insurance covers gaps in deductibles, requirements, and benefit periods.
• Dental insurance plans provide reimbursement for dental services such as diagnostics, restoration, surgery, and endodontics.
• Dental plans have basic/scheduled or non-scheduled formats.

Vision Insurance

• Vision Coverage (Eye Care Policies) offer eye exam, contact lens, eyeglasses, and laser surgery coverage.
• Vision care covers refraction and eyeglasses as optional for group health insurance usually pays a specific amount/ the cost of exam.
• Prescription drug insurance benefit reimburses drug expenses or issued a prescription drug card for deduction of each purchase.
• Hospital/Medical expense policy purchases the Hospital Indemnity Insurance, providing income when the insured is hospitalized.

Long Term Care

• Long-Term Care Insurance covers needs (due to sickness/illness) for an extended time and may be at home, adult day, or nursing home.
• Workers compensation helps cover loss of work due to injury and or sickness.
• Workers comp follows rules for the payment of the four types of benefits: medical, income, death, and rehabilitation.
• Specified Disease insurance is coverage supplements major medical coverage for single/group diseases.
• This insurance offers to pay for living expanses.

Other Programs Include:

• Accidental Death and Dismemberment Insurance (AD&D)
• Gap Insurance (critical illness)
• Accident insurance
• Fixed-benefit indemnity medical insurance

Federal and State Programs

• Most health care protection is provided by state/federal program.
• Medicare is a primary care source, effective in 1966 and taken place by social security.
• This expense protection to 65older, to those of any age suffering from end stage renal disease.
• Medicare offers Part A (home health/hospital with hospice).
• Medicare beneficiaries fund this coverage through coinsurance, premiums, and tax deductions in the Federal Insurance Trust Funds.
• Medicare limits hospital stays/skilled nursing facility care per the benefit period.
• A benefit period begins upon recipient entry to a location but ends if the recipient has exited for 60 + days.
• Medicare Part B covers supplies, surgical, and treatments (optional enrollment with monthly premiums).
• Part B covers visits, surgeries, outpatient, supplies, diagnostic tests and durable medical equipment.
• Medigap is a type of Medicare Supplemental Insurance Policies.
• Medicare Advantage Plans (Part C or MA Plans) enacted In 1997, for Medicare.
• MA allows Medicare beneficiaries to join privately run care plans.
• Medicare pays a set amounts for each enrollee, following Medicare rules.
• Medicare provides health/drug coverage.
• The Medicare Modernization Act (2003) launched Medicare Part D (Prescription Drug Coverage).
• Medicare Part D is provided by commercial insurers and through CMS in drug coverage with Medicare Advantage Plans.
• The TRICARE program is managed by the Department of Defense, combining military and civilian health care.
• TRICARE offers coverage meeting Affordable Care Act requirements for active, guard, reserves, and retired members of the uniformed services.
• The Federal Employees Health Benefits Program (FEHBP) a "managed competition" system with benefits to employees/retirees.
• With FEHBP, an employee can choose CDHPs, high deductible plans, health savings accounts, FFS/PPO plans or HMO as appropriate.

Medicaid Program

• Established in 1965, for low-income families, aged, blind, and disabled persons.
• Federally set eligibility/benefits with state administration.
• States set packages, administer processes that are consistent for all plans.
• Costs are shared between federal and state.
• The State Children's Health Insurance Program (CHIP) provides matching funds for lower income families that are not private enough for Medicaid.
• CHIP is administered on a state-level and is qualified by the state to determine.
• Marketplace are insurance exchanges.
• Individual/Family health insurance can receive subsidies to make coverage and care affordable.

Basic Legal Aspects

• Regulation of Health Insurance happens together by state/federal government.
• States have the authority to regulate, established through Law 15, also known as the McCarren-Ferguson Act.
• Congress passed this regulation in 1945 due to insurance remaining individually stated. McCarren-Ferguson Act allows federal insurance regulation in labor standards and antitrust matters.
• Plan Funding framework employment insurance varies bases purchased from self-insures or using a joint approach.
• Employers go through insurers with specific fees per person.
• Fully-Insured policies by insurance company, with premiums fixed for the year. Insurers provide coverage.
• Commercial health plans states, regulations, licensure, and laws to follow in these situations.
• Some employers insurance their plans but assuming all risk of 100%, can be covered by stop-loss insurance.
• Benefit plan falls within ERISA’s scope and is not regulated by the state.
• Employers create a can contact Insurance companies to complete admin services.
• Employee Benefits Security Administration (EBSA) the U.S. Department of Labor regulates pension and welfare benefit plans under ERISA.
• ERISA state regulates plans/funds that benefits retirement medical employee.
• ACA began to change the healthcare regulation.
• Federal government has the authority that applies several federal regulatory parameters.

State Anti-fraud Regulatory Requirements

• States that regulation over business insurance have the right of the authority.
• These Requirements may include: Suspected fraud report for fraud plan as both minimum SIU, and training.
• Annual reporting may be required.
• HIPAA amended ERISA, Health law and Internal Revenue code.
• The Two keys areas of are: Prevent the Healthcare fraud or Medical Liability Reform.
• HIPAA Secretary is increasing the use of the healthcare by standards of use and information.
• Results includes: Rules and Security and Unique. Identifies Rule.
• HIPAA created the Health Care Fraud and Abuse Control, (HCFAC) to combat fraud.
• Appropriations monies from the Medicare Funds to secure.
• FY The Secretary General certified $279.7 million.
• Congress appropriated $725 million.
• HIPAA Privacy Law disclosure of Protection, Health Information, any information held/payment.
• Include entities disclose HIP.

HIPAA

• Covered entities HIPAA facilitates healthcare operations and must disclose some information for transparency.
• HIPAA protects PHI and is paper based and electronic where, the 3 security rule areas applies: administrative, physical, and technical.
• To standardize and create HIPAA required compliance in 2007 through the Unique Identifiers Rule.
• HIPAA did replace identifiers. In 2009 HITECH part of stimulus to create a new tool, increasing from $25,000 to $1.5 million.
• Most Security breaches must be reported to the patient including the notification requirement.
• AKS includes Bribe or Rebate. The Civil Monitoring Penalties.

The ACA expands the Aks intent

• Individuals must have actual acknowledge or violations.
• Stark Referral Physician, prohibits physicians with indirect financial or interest.
• Penalties are non-payments which can’t Medicare.
• There are actions the false Claims Acts states against Persons that presents false federal.
• Government created penalties for False Claims (FCA), violations doubled for previous in effect
• The process by the whistleblower.

False Claims and Overpayments

• FCA providers have a returns of overpayments, returns and medicate.
• Overpayments are defined by Medicare and Medicaid An over Payment must be and returned by later.

Civil Monitoring

•The CMP and exclusion from help care.

• Examples of: false claims.
• The A false statement has a Federal care program.
• Title 11 of HIPAA states creates a federal offense of health care applies a "health program".
• Prohibits executing are committing to execute and deflators.

Compliance Plans

•HHS-OIG the compliance for various U.S. healthcare.

• Under all requires compliance plans The U.C. Sentencing.

The Rules of Affordable Care

Are Feb 2012.

• Section 6401 Enrollment, requirement, and are requirements/CHIP.

• Section 6402(h) Medicaid, payments.

• Key Federal, and Independent Agencies like: Center for Medicare Service

• April Secretary of all program to increase.

• Houses the Department Health Service like inspect.

State Agencies

• Medicaid Program Integrity Units a State agency developed policies.

• Center for Program Integrity under CMS

• Reviews every year

• Conduct fraud Units annual.

• State Medical protects like unlawful practice of medicine.

• State Medical has powers.

• Office of The Attorney.

• Insurance

Independant Organizations

A Medical specialty of boards is to evaluate candidates in specialty.

• The ACA will clarify for the claim.

Domain 1VI Federal Antitrust

• Laws and Anti-Fraud Sharing •Federal Antitrust the protect consumers Competition for a Market Services. some Activities that is and rule federal state laws.

• In a health insurance contact below activities.

• (1.Collective Decisions)(2.collective Decisions not to cover or to certain items or service (3.Discussions to about such topics.) Antitrust Information Sharing

• Exchange sharing like a fighting that Is a generally is as if as lawful.

• Law and sharing Private. • Information Sharing Principles.

• Organizations against a provider, A shared Only a decision of a and that conduct. Distribution Outside The Sul.

• Communication law and limited and never Discontinuing, or relationships.

• Immunity privilege is to defamation.

• Some State laws enact.

• Immunity the State, and From.

• These Statutes a insurer being used.

• For fraud they will a against bad faith and malice, Beyond the Immunity Laws a provide a level of protection communication acts the basic, the fraud is to consider it

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