Quality Assurance & Improvement Flashcards

A claims manager reviews a random sample of closed files to measure whether best practices were followed. What is this activity most commonly called?

Answer: Claim audit

A claim audit checks files against established standards and best practices to measure performance quality.

Which term describes payments on claims that exceed what should have been paid because of errors, poor investigation, or weak negotiation?

Answer: Claim leakage

Claim leakage is money lost through inefficient or incorrect claim handling practices.

An insurer's audit finds adjusters routinely miss the state-required deadline to acknowledge new claims. Which law is most directly at risk of being violated?

Answer: Unfair Claims Settlement Practices Act

State unfair claims settlement practices laws set time limits for acknowledging and responding to claims.

Why is a statistically random sample preferred when selecting files for a quality review?

Answer: It produces results more representative of the whole claim population

Random sampling reduces selection bias so findings can be generalized to all claims.

Which metric best measures how accurately initial reserves predict final claim costs?

Answer: Reserve adequacy or reserve development

Reserve development compares initial reserves to ultimate paid amounts to show reserving accuracy.

A claims department holds sessions where several adjusters evaluate the same file and compare their conclusions. What is the main purpose of this practice?

Answer: Calibrating judgment for consistent outcomes

Calibration sessions align adjusters' judgment so similar claims receive similar treatment.

Which is an example of a lagging indicator of claim quality?

Answer: Total closed-claim indemnity paid compared with benchmarks

Lagging indicators measure outcomes after the fact, such as final paid amounts.