Insurance Quality Control & Assurance 3

Question 1

In insurance, 'leakage' in the context of QC refers to:

Accepted Answer

Overpayments on claims due to process or judgment errors

Answer

Claim leakage is money paid beyond the appropriate settlement amount due to errors, fraud, or poor claims management practices.

Question 2

Which of the following is a leading indicator of future claims quality problems?

Accepted Answer

High employee turnover in the claims department

Answer

High turnover reduces experienced staff, leading to more errors and inconsistent claim handling before quality metrics even reflect the decline.

Question 3

An insurer's QA scorecard shows a spike in 'late acknowledgment' errors. Which regulatory requirement is most at risk?

Accepted Answer

Prompt payment laws requiring timely claim acknowledgment within a set period

Answer

Most states mandate insurers acknowledge claims within 10–15 days, and late acknowledgment errors directly indicate violations of prompt payment laws.

Question 4

What is the main goal of 'calibration sessions' in an insurance QA program?

Accepted Answer

To align auditors on scoring criteria so evaluations are consistent

Answer

Calibration sessions bring QA reviewers together to score the same files and reconcile differences, ensuring uniform evaluation standards.

Question 5

A market conduct examination by a state insurance department primarily evaluates:

Accepted Answer

Whether the insurer's business practices comply with state laws and regulations

Answer

Market conduct exams assess how an insurer treats policyholders and whether its practices — including claims handling — follow state laws.

Insurance Practice Test

Insurance Practice Test

Insurance Quality Control & Assurance 3