ACE Fraud Detection & Prevention 4

Question 1

Which data analytics technique is most effective for identifying organized fraud rings across multiple policyholders?

Accepted Answer

Social network analysis mapping relationships between claimants, providers, and attorneys

Answer

Social network analysis reveals hidden connections—shared phone numbers, addresses, or attorneys—among claimants that indicate coordinated fraud rings.

Question 2

Under the Health Insurance Portability and Accountability Act (HIPAA), when can an insurer share medical claim data with its SIU for fraud investigation without patient authorization?

Accepted Answer

When the disclosure is for healthcare fraud and abuse detection purposes

Answer

HIPAA's fraud exception permits covered entities to disclose PHI for healthcare fraud and abuse detection without individual authorization.

Question 3

What is the primary purpose of a 'fraud score' generated at the point of first notice of loss (FNOL)?

Accepted Answer

To prioritize claims for SIU referral based on risk indicators

Answer

Fraud scores at FNOL help claims handlers triage which claims warrant SIU investigation, enabling early intervention before payments are made.

Question 4

Which ACORD form is used to report commercial general liability claims, and which field is most critical for fraud detection?

Accepted Answer

ACORD 5 — witness information

Answer

On the ACORD 5 (General Liability Notice of Occurrence/Claim), witness information is critical because fraudulent claims often lack credible independent witnesses.

Question 5

A body shop submits identical repair estimates for 15 different vehicles of the same make and model following separate accidents. What fraud scheme does this most likely represent?

Accepted Answer

Collision repair fraud — using template estimates without actually inspecting vehicles

Answer

Template estimates submitted without actual vehicle inspections indicate collision repair fraud, where shops bill for work not performed or not needed.

(ACE) ACORD Certified Expert Practice Test

(ACE) ACORD Certified Expert Practice Test

ACE Fraud Detection & Prevention 4