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 medical provider submits bills for 30-minute office visits but office surveillance shows patients in and out in under five minutes. This is an example of:
Answer: Billing for services not rendered or rendered at a different level than billed
Billing for a duration or complexity of service that surveillance evidence contradicts indicates fraudulent upcoding or billing for services not actually rendered.
Which of the following is the BEST example of 'hard fraud'?
Answer: Staging a vehicle theft to collect the insurance proceeds
Hard fraud is a deliberate, premeditated criminal act such as staging a theft, fire, or accident specifically to collect insurance money.
What is the primary purpose of an Examination Under Oath (EUO) in a suspected fraud scenario?
Answer: To obtain sworn testimony that can be used to evaluate the claim and, if necessary, in legal proceedings
An EUO produces sworn testimony under oath, providing a legally significant statement that can be used to evaluate coverage and as evidence in litigation or prosecution.
A repair shop estimates vehicle damage at $12,000 but a second estimate comes in at $4,500 for the same damage. The inflated estimate shop has appeared in prior SIU cases. What should the adjuster do?
Answer: Refer to SIU and consider involving law enforcement given the repair shop's fraud history
A shop with a prior SIU history combined with a dramatically inflated estimate is a strong indicator of repair fraud, warranting SIU referral and potential law enforcement notification.
What does the 'fraud triangle' concept help explain about why individuals commit insurance fraud?
Answer: It identifies the three elements that converge to enable fraud: pressure, opportunity, and rationalization
The fraud triangle explains that fraud occurs when a person faces financial pressure, perceives an opportunity, and rationalizes the behavior as acceptable.
A claimant's attorney sends a demand letter citing medical bills totaling $95,000 for soft-tissue injuries from a low-speed impact. The vehicle damage was $800. What is the primary fraud indicator here?
Answer: Medical expenses grossly disproportionate to the physical damage in the accident
A dramatic disparity between minor property damage and massive medical billing is a hallmark indicator of exaggerated injury fraud.
Which regulatory body in the United States serves as the primary recipient of Suspicious Activity Reports (SARs) related to insurance fraud at the federal level?
Answer: The Financial Crimes Enforcement Network (FinCEN) of the U.S. Treasury
FinCEN, part of the U.S. Treasury, receives SARs from financial institutions including insurers for federal-level financial crime tracking and investigation.