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 claimant who previously worked with a chiropractor files injury claims after multiple unrelated accidents over three years, always treating with the same provider. This pattern suggests:
Answer: A potential provider-claimant fraud ring
Repeated use of the same provider across multiple unrelated claims is a hallmark indicator of a coordinated provider-claimant fraud scheme.
Which of the following BEST describes 'application fraud' in the insurance context?
Answer: Misrepresenting material facts on an insurance application to obtain coverage or lower premiums
Application fraud is the misrepresentation of material information at the time of policy application to obtain coverage that would otherwise be denied or to reduce premiums.
What is the significance of a 'loss run report' in evaluating a potential fraud referral?
Answer: It shows the claimant's prior claim history with all carriers for a specific period
A loss run report reveals prior claim activity, helping identify claimants with suspiciously frequent or patterned losses across insurers.
Which behavioral characteristic during a recorded statement is a recognized fraud indicator?
Answer: Offering unsolicited details about why they could not have committed fraud
Volunteering unprompted explanations of innocence is a recognized deception indicator associated with rehearsed or fabricated accounts.
When a claim involves suspected arson for profit, which professional should be among the FIRST external resources consulted?
Answer: Certified fire investigator
A certified fire investigator determines origin and cause, which is foundational to any arson-for-profit investigation before other experts are engaged.
A claimant is slow to return calls, unavailable for an EUO, and repeatedly changes their attorney. This pattern of behavior is:
Answer: An evasion pattern that is a recognized fraud indicator
Persistent evasion of the claims process, including avoiding examinations under oath, is a recognized behavioral indicator of potential fraud.
Under most state anti-fraud statutes, which action by a claimant constitutes insurance fraud?
Answer: Knowingly filing a false or inflated claim with intent to defraud the insurer
Insurance fraud statutes require knowing and intentional misrepresentation with intent to defraud; mere coverage disputes or disagreements are not fraud.