CCA Fraud Detection and Prevention Flashcards
6 cards from real CCA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 CCA Fraud Detection and Prevention flashcards as text
What is 'arson for profit' in the context of insurance fraud?
Answer: Deliberately setting fire to property to collect insurance proceeds
Arson for profit is hard fraud where the policyholder intentionally sets fire to their property — often when facing financial difficulty — to collect insurance money.
Which of the following best describes 'premium fraud'?
Answer: Misrepresenting information at application to obtain lower premiums
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.
A doctor submits identical billing codes for every patient regardless of services provided. This is an example of:
Answer: Cookie-cutter billing fraud
Cookie-cutter (or template) billing fraud occurs when a provider uses identical billing codes for all patients without performing individualized services, inflating reimbursements.
Social media posts showing a claimant performing physical activities they claim they cannot do are best used by adjusters to:
Answer: Support an SIU referral and potential fraud investigation
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.
What is 'index system' used for in insurance fraud detection?
Answer: To cross-reference claim data across multiple insurers to identify claimants involved in suspicious patterns
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.
Under most state laws, adjusters and insurers are required to report suspected fraud to:
Answer: The state department of insurance and/or law enforcement
Most states mandate that insurers report suspected fraud to the state insurance department and/or law enforcement, and many provide immunity from civil liability for good-faith fraud reports.