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
In insurance, 'leakage' in the context of QC refers to:
Answer: Overpayments on claims due to process or judgment errors
Claim leakage is money paid beyond the appropriate settlement amount due to errors, fraud, or poor claims management practices.
Which of the following is a leading indicator of future claims quality problems?
Answer: High employee turnover in the claims department
High turnover reduces experienced staff, leading to more errors and inconsistent claim handling before quality metrics even reflect the decline.
An insurer's QA scorecard shows a spike in 'late acknowledgment' errors. Which regulatory requirement is most at risk?
Answer: Prompt payment laws requiring timely claim acknowledgment within a set period
Most states mandate insurers acknowledge claims within 10–15 days, and late acknowledgment errors directly indicate violations of prompt payment laws.
What is the main goal of 'calibration sessions' in an insurance QA program?
Answer: To align auditors on scoring criteria so evaluations are consistent
Calibration sessions bring QA reviewers together to score the same files and reconcile differences, ensuring uniform evaluation standards.
A market conduct examination by a state insurance department primarily evaluates:
Answer: Whether the insurer's business practices comply with state laws and regulations
Market conduct exams assess how an insurer treats policyholders and whether its practices — including claims handling — follow state laws.
Which quality assurance technique involves shadowing a claims adjuster during live calls to evaluate performance?
Answer: Side-by-side monitoring
Side-by-side monitoring allows QA staff to observe and score an adjuster's real-time interactions as they happen.
In a root cause analysis following repeated QA failures, which tool maps the sequence of causes leading to a defect?
Answer: Fishbone (Ishikawa) diagram
A fishbone diagram visually traces contributing causes back to a central problem, making it ideal for insurance QA root cause investigations.