Insurance Quality Control & Assurance 2

Question 1

Which metric is most commonly used to measure claim settlement accuracy in an insurance QA program?

Accepted Answer

Error rate per 100 claims processed

Answer

Error rate per 100 claims processed is the standard QA metric for measuring how accurately claims are being settled.

Question 2

What is the primary purpose of a file review audit in insurance quality assurance?

Accepted Answer

To verify that claim files comply with handling guidelines and regulations

Answer

File review audits evaluate whether claim handlers are following established guidelines, best practices, and regulatory requirements.

Question 3

In insurance QA, a 'corrective action plan' (CAP) is triggered when:

Accepted Answer

Quality scores fall below an established threshold

Answer

A corrective action plan is initiated when quality metrics drop below the minimum acceptable performance level to address the root cause.

Question 4

Which of the following best describes 'inter-rater reliability' in an insurance QA context?

Accepted Answer

The consistency of results when different auditors review the same file

Answer

Inter-rater reliability measures how consistently different QA reviewers score the same claim file, ensuring audit fairness.

Question 5

A 'random sampling' QA approach in claims auditing means:

Accepted Answer

Files are selected without bias to represent the entire claims population

Answer

Random sampling ensures every claim has an equal chance of selection, providing an unbiased picture of overall performance.

Insurance Practice Test