Quality Assurance & Improvement Flashcards

A claims department sets a goal of contacting every insured within 24 hours of a reported loss. What type of standard is this?

Answer: Service-level or timeliness standard

A contact-within-24-hours goal is a timeliness service standard for claim handling.

Which control best prevents an adjuster from settling claims beyond their competence or the insurer's risk tolerance?

Answer: Settlement authority limits with escalation requirements

Authority limits require larger or riskier settlements to be approved by more experienced staff.

A quality review shows one adjuster's average liability settlements are much higher than peers on similar claims. What is the most appropriate next step?

Answer: Review the files to determine whether the variance reflects claim facts or handling issues

Outliers should be investigated to see whether the facts justify them before taking action.

Which is a key benefit of using a standardized audit scoring form across all reviewers?

Answer: Consistent, comparable results across adjusters and offices

A standardized form ensures every file is judged on the same criteria so results can be compared.

Special investigation unit (SIU) referral rates are tracked in a quality program primarily to evaluate what?

Answer: Whether adjusters properly identify and refer suspected fraud

Tracking SIU referrals shows whether adjusters recognize fraud indicators and follow referral procedures.

Which metric would best show the efficiency of claim handling expenses relative to losses paid?

Answer: Loss adjustment expense ratio

The LAE ratio compares claim handling costs to losses, showing handling efficiency.

A claims leader wants employees to suggest small, ongoing process changes rather than waiting for major overhauls. Which philosophy does this reflect?

Answer: Kaizen or continuous improvement

Kaizen emphasizes small, incremental improvements suggested by employees at every level.