CCA CCA Fraud Detection and Prevention 2

Question 1

What is 'arson for profit' in the context of insurance fraud?

Accepted Answer

Deliberately setting fire to property to collect insurance proceeds

Answer

Arson for profit is hard fraud where the policyholder intentionally sets fire to their property — often when facing financial difficulty — to collect insurance money.

Question 2

Which of the following best describes 'premium fraud'?

Accepted Answer

Misrepresenting information at application to obtain lower premiums

Answer

Premium fraud occurs when an applicant misrepresents facts (such as the primary driver, garaging location, or vehicle use) to pay lower premiums than they should.

Question 3

A doctor submits identical billing codes for every patient regardless of services provided. This is an example of:

Accepted Answer

Cookie-cutter billing fraud

Answer

Cookie-cutter (or template) billing fraud occurs when a provider uses identical billing codes for all patients without performing individualized services, inflating reimbursements.

Question 4

Social media posts showing a claimant performing physical activities they claim they cannot do are best used by adjusters to:

Accepted Answer

Support an SIU referral and potential fraud investigation

Answer

Social media evidence showing activities inconsistent with claimed disability can support an SIU fraud referral and, if confirmed, may result in claim denial or prosecution.

Question 5

What is 'index system' used for in insurance fraud detection?

Accepted Answer

To cross-reference claim data across multiple insurers to identify claimants involved in suspicious patterns

Answer

Index systems (like ISO ClaimSearch) allow insurers to share and compare claim data to identify individuals who have filed similar or suspicious claims with multiple companies.

(CCA) Certified Claims Adjuster Practice Test

(CCA) Certified Claims Adjuster Practice Test

CCA CCA Fraud Detection and Prevention 2