CFS Insurance Fraud Investigation 3

Question 1

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:

Accepted Answer

Phantom billing

Answer

Phantom billing involves charging for services never rendered, such as visits that physically could not have occurred given capacity constraints.

Question 2

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:

Accepted Answer

Inflated repair fraud

Answer

Inflated repair fraud involves submitting estimates with artificially elevated costs, including using rates from higher-cost jurisdictions.

Question 3

Under the McCarran-Ferguson Act, regulation of insurance fraud is PRIMARILY the responsibility of:

Accepted Answer

State insurance departments

Answer

The McCarran-Ferguson Act grants states primary authority to regulate the insurance industry, including fraud oversight.

Question 4

Which type of insurance fraud scheme involves medical providers paying patients cash or other incentives to use their services and file claims?

Accepted Answer

Medical mills

Answer

Medical mills recruit patients through paid recruiters and generate fraudulent claims for unnecessary or phantom treatments.

Question 5

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:

Accepted Answer

Swoop-and-squat victim

Answer

In a swoop-and-squat scheme, one car cuts off another and brakes suddenly, making the innocent rear driver appear at fault.

(CFS) Certified Fraud Specialist Practice Test

(CFS) Certified Fraud Specialist Practice Test

CFS Insurance Fraud Investigation 3