Quality Assurance & Improvement Flashcards

Which file documentation practice most strongly supports a quality audit finding that a claim was handled in good faith?

Answer: Timely, objective file notes explaining decisions and contacts

Contemporaneous, objective notes show the reasoning and timeliness behind claim decisions.

A market conduct examination of an insurer's claims department is typically performed by whom?

Answer: A state insurance department

State insurance regulators conduct market conduct exams to assess compliance with claim handling laws.

Which is the best reason to include customer satisfaction surveys in a claim quality program?

Answer: They reveal service issues that file audits may miss

Surveys capture the claimant's experience, such as communication quality, that files may not show.

An auditor finds an adjuster paid a property claim without verifying the policy was in force on the date of loss. Which best-practice area was missed?

Answer: Coverage verification

Confirming the policy was in force and covering the loss is a fundamental first step in claim handling.

Why might a claims department track the reopened-claim rate as a quality measure?

Answer: High reopen rates can signal claims were closed prematurely or incompletely

Frequent reopenings may indicate files were closed before all issues were resolved.

Which situation represents a conflict between productivity goals and claim quality?

Answer: Adjusters are rewarded solely for closing files quickly, encouraging underpayment or overpayment

Rewarding speed alone can push adjusters to skip investigation, hurting accuracy and fairness.

An internal claim audit is most useful when its results are used to do what?

Answer: Identify training needs and process improvements

Audit results should feed back into training and process changes to improve future performance.