Insurance Quality Control & Assurance 4

Question 1

Which of the following best describes a 'closed-file review' in insurance QA?

Accepted Answer

Auditing claim files after they have been fully settled and closed

Answer

A closed-file review examines settled claims to assess whether the handling, documentation, and payment decisions were appropriate.

Question 2

An insurer implements a '100% review' QA approach for newly hired adjusters. This is an example of:

Accepted Answer

Universal sampling for high-risk populations

Answer

New employees represent a higher risk of errors, so reviewing all of their work (universal sampling) mitigates quality risk until competence is proven.

Question 3

A QA analyst notices that denial rates are significantly higher for a specific adjuster compared to peers. The BEST next step is to:

Accepted Answer

Conduct a targeted file review to determine if denials are justified or erroneous

Answer

A targeted review identifies whether the outlier denial rate reflects poor judgment or legitimate pattern recognition before any action is taken.

Question 4

In insurance quality management, 'Six Sigma' methodology aims to reduce defects to approximately:

Accepted Answer

3.4 per million opportunities

Answer

Six Sigma targets 3.4 defects per million opportunities, representing a near-perfect process quality level.

Question 5

Which of the following is an example of a 'critical error' in an insurance claims QA scorecard?

Accepted Answer

Paying a claim for a coverage that was explicitly excluded under the policy

Answer

Paying a claim for an excluded coverage is a critical error because it results in direct financial harm and potential regulatory violation.

Insurance Practice Test

Insurance Practice Test

Insurance Quality Control & Assurance 4