CPHRM Claims Management 4 — Questions and Answers
Question 1: In the context of healthcare claims, 'occurrence reporting' is BEST described as:
- Filing a claim with the insurer after a verdict
- Notifying the insurer of events that may lead to a claim, even before one is filed (Correct answer)
- Reporting adverse events to state health departments
- Documenting outcomes in the patient's medical record
Correct answer: Notifying the insurer of events that may lead to a claim, even before one is filed
Occurrence reporting to insurers involves notifying them of incidents or events with claim potential before a formal claim is made, preserving coverage and enabling early investigation.
Question 2: Which principle guides the concept that a healthcare provider owes a heightened standard of care to patients who are incapacitated or vulnerable?
- Assumption of risk
- Comparative fault
- Special relationship doctrine (Correct answer)
- Last clear chance rule
Correct answer: Special relationship doctrine
The special relationship doctrine recognizes that certain relationships, such as provider-patient, impose heightened duties of care and protection.
Question 3: A hospital settles a malpractice claim for $150,000. Under the National Practitioner Data Bank (NPDB) rules, this payment must be reported:
- Only if the payment exceeds $500,000
- Within 30 days of the payment (Correct answer)
- Only when the physician is found liable by a court
- At the hospital's discretion if the physician was not named
Correct answer: Within 30 days of the payment
NPDB regulations require that all medical malpractice payments made on behalf of a licensed healthcare practitioner be reported within 30 days.
Question 4: Which alternative dispute resolution method uses a neutral third party who renders a binding decision?
- Mediation
- Arbitration (Correct answer)
- Negotiation
- Early neutral evaluation
Correct answer: Arbitration
Arbitration involves a neutral arbitrator who hears both sides and issues a binding decision, unlike mediation where the neutral only facilitates negotiation.
Question 5: In a comparative negligence jurisdiction, a plaintiff found 40% at fault for their own injury can recover:
- Nothing, because they contributed to the injury
- 60% of the total damages awarded (Correct answer)
- 100% of the damages from the most negligent defendant
- 40% of the total damages awarded
Correct answer: 60% of the total damages awarded
Under pure comparative negligence, a plaintiff's recovery is reduced by their percentage of fault, so 40% fault yields 60% of the total damages.
Question 6: What is the function of a 'hammer clause' in a liability insurance policy?
- It mandates that all claims go to trial
- It allows the insurer to limit its liability if the insured refuses a reasonable settlement (Correct answer)
- It requires the insured to pay defense costs upfront
- It authorizes the insurer to appoint defense counsel without consent
Correct answer: It allows the insurer to limit its liability if the insured refuses a reasonable settlement
A hammer clause (or consent-to-settle clause) penalizes the insured by capping insurer liability at the rejected settlement amount if the insured refuses a reasonable offer.
Question 7: Which metric is MOST useful for evaluating the effectiveness of a healthcare organization's claims management program over time?
- Number of claims filed per year
- Average claim cost and closure rate trends (Correct answer)
- Total litigation hours logged by defense counsel
- Number of incident reports submitted
Correct answer: Average claim cost and closure rate trends
Tracking average claim cost and closure rate trends reveals whether claims are being resolved efficiently and at lower financial impact over time.
CPHRM Claims Management 4
In the context of healthcare claims, 'occurrence reporting' is BEST described as: