SIU Referral & Fraud Indicators Flashcards
7 cards from real CCP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 SIU Referral & Fraud Indicators flashcards as text
A homeowner files a claim for fire damage and the fire investigator determines the fire's origin was incendiary. Which factor would MOST strengthen a fraud referral?
Answer: The homeowner had significantly increased the policy limits 60 days before the fire
Substantially increasing coverage shortly before a suspicious loss is a key fraud indicator, especially when combined with an incendiary origin finding.
Which type of fraud involves a legitimate accident but exaggerated injury claims or inflated repair estimates?
Answer: Soft fraud
Soft fraud involves opportunistic exaggeration of a real claim, such as inflating damages or overstating injuries after an actual accident.
An injured worker's social media posts show them playing sports the week after claiming total disability. This is primarily an indicator of:
Answer: Malingering or workers' compensation fraud
Social media activity inconsistent with claimed disability is a strong indicator of malingering or workers' compensation fraud warranting SIU referral.
Under the ISO ClaimSearch system, what primary function does the database serve in fraud detection?
Answer: It identifies patterns of prior claims across multiple insurers
ISO ClaimSearch cross-references claims data across insurers to reveal suspicious claim histories or patterns that a single insurer would not see alone.
A claimant reports a jewelry theft but cannot provide any purchase receipts, photos, or appraisals for the claimed items. This lack of documentation is:
Answer: A fraud indicator that may warrant further investigation
Inability to substantiate high-value items is a fraud indicator that warrants additional investigation but alone does not prove fraud.
What is the term for a scheme in which medical providers bill for services at a higher complexity level than was actually performed?
Answer: Upcoding
Upcoding is fraudulent billing that uses higher-level CPT codes than the services rendered actually warrant to receive greater reimbursement.
Which individual is typically NOT part of the core SIU team that handles a formal fraud investigation?
Answer: Defense attorney retained by the insurer
Defense attorneys are engaged for litigation, not as core SIU team members; SIU teams typically include investigators, analysts, and law enforcement liaisons.