CCP SIU Referral & Fraud Indicators 2 — Questions and Answers
Question 1: A claimant reports a vehicle theft but the GPS data shows the vehicle was stationary at a different location than reported. What fraud indicator does this represent?
- Exaggerated injury claim
- Physical evidence inconsistency (Correct answer)
- Multiple prior claims
- Late reporting
Correct answer: Physical evidence inconsistency
When physical or electronic evidence contradicts the claimant's account, it is a classic physical evidence inconsistency fraud indicator requiring SIU referral.
Question 2: Which of the following is the MOST significant red flag when a medical provider submits bills for a claimant?
- Bills submitted within 30 days of treatment
- Billing for services on dates the claimant was hospitalized elsewhere (Correct answer)
- Minor spelling errors on the HCFA form
- Use of common CPT billing codes
Correct answer: Billing for services on dates the claimant was hospitalized elsewhere
Billing for services rendered on dates when the patient was provably elsewhere indicates phantom billing fraud.
Question 3: A newly purchased policy is followed within days by a large theft claim. This scenario most closely resembles which fraud scheme?
- Soft fraud
- Policy inception fraud (Correct answer)
- Workers' compensation fraud
- Application misrepresentation
Correct answer: Policy inception fraud
Policy inception fraud occurs when a policy is obtained specifically to file an immediate fraudulent claim.
Question 4: When an SIU investigation is opened, what obligation does the insurer generally have under most state regulations?
- Immediately deny the claim pending investigation
- Report fraud findings to the state insurance fraud bureau within a specified timeframe (Correct answer)
- Notify the claimant that fraud is suspected before taking any action
- Suspend all communications with the claimant
Correct answer: Report fraud findings to the state insurance fraud bureau within a specified timeframe
Most states mandate that insurers report suspected fraud to the state insurance fraud bureau or DOI within a specific period after discovery.
Question 5: A claimant's recorded statement contains inconsistencies about how the accident occurred. Which action should the adjuster take FIRST?
- Close the claim as fraudulent immediately
- Document the inconsistencies and consider an SIU referral (Correct answer)
- Ignore inconsistencies if injuries are minor
- Contact the claimant's attorney before proceeding
Correct answer: Document the inconsistencies and consider an SIU referral
The adjuster should document all inconsistencies and evaluate whether they rise to the level requiring an SIU referral per company guidelines.
Question 6: Which scenario is a typical indicator of a staged auto accident?
- A single-vehicle accident on a busy highway
- Multiple unrelated passengers in both vehicles who all claim injuries (Correct answer)
- Damage consistent with the reported impact speed
- The at-fault driver fully cooperates with the investigation
Correct answer: Multiple unrelated passengers in both vehicles who all claim injuries
A disproportionate number of injury claimants who are strangers to each other and to the vehicles is a hallmark of staged accident rings.
Question 7: What is 'paper accident' fraud?
- Filing a claim using forged accident reports
- Reporting a minor accident as more severe than it actually was
- Reporting an accident that never occurred to collect insurance proceeds (Correct answer)
- Submitting duplicate claims to multiple insurers
Correct answer: Reporting an accident that never occurred to collect insurance proceeds
A 'paper accident' is a fictitious collision that never happened, with all documentation fabricated to support the fraudulent claim.
CCP SIU Referral & Fraud Indicators 2
A claimant reports a vehicle theft but the GPS data shows the vehicle was stationary at a different location than reported.
What fraud indicator does this represent?