Quality Control & Assurance Flashcards
7 cards from real Insurance practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Quality Control & Assurance flashcards as text
Which metric is most commonly used to measure claim settlement accuracy in an insurance QA program?
Answer: Error rate per 100 claims processed
Error rate per 100 claims processed is the standard QA metric for measuring how accurately claims are being settled.
What is the primary purpose of a file review audit in insurance quality assurance?
Answer: To verify that claim files comply with handling guidelines and regulations
File review audits evaluate whether claim handlers are following established guidelines, best practices, and regulatory requirements.
In insurance QA, a 'corrective action plan' (CAP) is triggered when:
Answer: Quality scores fall below an established threshold
A corrective action plan is initiated when quality metrics drop below the minimum acceptable performance level to address the root cause.
Which of the following best describes 'inter-rater reliability' in an insurance QA context?
Answer: The consistency of results when different auditors review the same file
Inter-rater reliability measures how consistently different QA reviewers score the same claim file, ensuring audit fairness.
A 'random sampling' QA approach in claims auditing means:
Answer: Files are selected without bias to represent the entire claims population
Random sampling ensures every claim has an equal chance of selection, providing an unbiased picture of overall performance.
Which regulation most directly requires insurance carriers to maintain quality assurance programs for claims handling in the US?
Answer: State Unfair Claims Settlement Practices Acts
State Unfair Claims Settlement Practices Acts establish standards for timely and fair claims handling that QA programs must ensure compliance with.
What does a 'touchpoint audit' evaluate in insurance operations?
Answer: Each customer interaction point across the service lifecycle
A touchpoint audit assesses quality at every stage a customer contacts the insurer — from first notice of loss through final payment.