RIA TPA & Carrier Scope Negotiation 3 — Questions and Answers
Question 1: A TPA 'preferred vendor' agreement typically requires restorers to:
- Set their own pricing independently
- Adhere to the TPA's pricing guidelines and reporting requirements in exchange for referrals (Correct answer)
- Obtain written approval from the insured before every action
- Bypass the adjuster and bill the carrier directly
Correct answer: Adhere to the TPA's pricing guidelines and reporting requirements in exchange for referrals
Preferred vendor agreements trade referral volume for compliance with the TPA's pricing, documentation, and communication protocols.
Question 2: Which negotiation tactic is most effective when a carrier denies coverage for a line item without providing a written explanation?
- Immediately escalate to litigation
- Request a written denial with the specific policy exclusion cited (Correct answer)
- Remove the line item and absorb the cost
- Ask the insured to call the carrier and complain
Correct answer: Request a written denial with the specific policy exclusion cited
Requiring the carrier to cite the specific policy exclusion forces accountability and often results in reversal of improper denials.
Question 3: In a water damage claim, 'scope creep' during negotiation usually refers to:
- The insured adding unrelated upgrades to the claim (Correct answer)
- Items in the estimate growing beyond what the loss actually caused
- The TPA expanding their oversight role
- Moisture spreading to additional areas after the claim is filed
Correct answer: The insured adding unrelated upgrades to the claim
Scope creep in negotiations most commonly means the insured or contractor attempting to include items not caused by the covered peril.
Question 4: A restorer discovers hidden mold behind drywall removed during water mitigation. To include mold remediation in the scope, the restorer must first:
- Begin remediation immediately without notifying anyone
- Notify the carrier or TPA and obtain written authorization before proceeding (Correct answer)
- Bill the mold work separately to a private party
- Wait until the final walkthrough to disclose the finding
Correct answer: Notify the carrier or TPA and obtain written authorization before proceeding
Written authorization from the carrier or TPA must be obtained before beginning remediation to ensure coverage and avoid scope disputes.
Question 5: When a TPA's field adjuster and the restorer cannot agree on a scope, the standard next escalation step is to:
- File a complaint with the state insurance commissioner
- Request review by the TPA's desk adjuster supervisor or technical specialist (Correct answer)
- Demand appraisal under the insurance policy
- Withdraw from the project and send a final invoice
Correct answer: Request review by the TPA's desk adjuster supervisor or technical specialist
Escalating to a supervisor or technical specialist within the TPA is the standard internal resolution step before external options.
Question 6: Which IICRC document is most relevant when negotiating the class of water damage and the resulting drying scope?
- IICRC S520
- IICRC S500 (Correct answer)
- IICRC R520
- IICRC BSR-IICRC-S100
Correct answer: IICRC S500
IICRC S500 is the Standard for Professional Water Damage Restoration and defines water categories and classes used in scope development.
Question 7: A carrier requests a photo of every piece of equipment on-site each day during mitigation. This requirement is best described as:
- An unreasonable invasion of privacy
- A standard TPA documentation protocol for equipment verification (Correct answer)
- A violation of the restorer's trade secrets
- Optional if the restorer uses GPS tracking software
Correct answer: A standard TPA documentation protocol for equipment verification
Daily equipment photo documentation is a common TPA protocol to verify deployed equipment and support billing accuracy.
RIA TPA & Carrier Scope Negotiation 3
A TPA 'preferred vendor' agreement typically requires restorers to: