Insurance Fraud Investigation Flashcards
7 cards from real CFS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Insurance Fraud Investigation flashcards as text
A medical provider bills an insurer for 30-minute office visits for 50 patients on the same day, but clinic records show a maximum capacity of 20 patients daily. This is an example of:
Answer: Phantom billing
Phantom billing involves charging for services never rendered, such as visits that physically could not have occurred given capacity constraints.
An insurance fraud investigator finds that a body shop submitted repair estimates using labor rates and parts prices from a state where costs are significantly higher than the loss location. This scheme is called:
Answer: Inflated repair fraud
Inflated repair fraud involves submitting estimates with artificially elevated costs, including using rates from higher-cost jurisdictions.
Under the McCarran-Ferguson Act, regulation of insurance fraud is PRIMARILY the responsibility of:
Answer: State insurance departments
The McCarran-Ferguson Act grants states primary authority to regulate the insurance industry, including fraud oversight.
Which type of insurance fraud scheme involves medical providers paying patients cash or other incentives to use their services and file claims?
Answer: Medical mills
Medical mills recruit patients through paid recruiters and generate fraudulent claims for unnecessary or phantom treatments.
A staged auto accident ring recruits participants to deliberately cause collisions with innocent drivers. The BEST term for the innocent driver in this scheme is:
Answer: Swoop-and-squat victim
In a swoop-and-squat scheme, one car cuts off another and brakes suddenly, making the innocent rear driver appear at fault.
An SIU analyst notices that multiple unrelated auto claims share the same body shop, the same attorney, and the same medical clinic. This network analysis finding MOST suggests:
Answer: An organized fraud ring
Repeated linkage of the same vendors and professionals across unrelated claims is a strong indicator of an organized fraud network.
When an insurer's SIU refers a fraud case to law enforcement, which federal statute is MOST commonly used to prosecute multi-state insurance fraud conspiracies?
Answer: 18 U.S.C. § 1033 (insurance fraud)
18 U.S.C. § 1033 specifically criminalizes fraud against insurance companies in or affecting interstate commerce.