Fraud Detection & Prevention Flashcards
7 cards from real CALA practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Fraud Detection & Prevention flashcards as text
A claimant reports a burglary but cannot provide receipts or photos of the stolen items. Which investigative step is most appropriate?
Answer: Request a recorded statement and supporting documentation
Requesting a recorded statement and supporting documentation is standard practice to verify ownership and the legitimacy of a burglary claim.
Which pattern most strongly suggests organized auto insurance fraud in a staged accident ring?
Answer: Multiple claimants from the same household involved in separate minor accidents
Multiple claimants from the same household appearing in separate minor accidents is a hallmark indicator of organized staged accident fraud rings.
Under the Insurance Fraud Prevention Act framework, insurers are generally required to report suspected fraud to which entity?
Answer: The state Department of Insurance fraud division
Most states require insurers to report suspected fraud to the state Department of Insurance fraud division, though NICB reporting may also be required.
A contractor submits invoices for roof repairs that appear inconsistent with a property's pre-loss condition. What is this an example of?
Answer: Hard fraud involving an inflated claim
Submitting inflated invoices for repairs exceeding actual damage is a form of hard fraud, typically involving deliberate material misrepresentation.
Which of the following best defines 'premium fraud' in the insurance context?
Answer: Misrepresenting risk characteristics to obtain lower premiums
Premium fraud involves misrepresenting material facts about the insured risk—such as garaging location or driver history—to secure a lower premium.
An adjuster notices that a workers' compensation claimant's medical bills include treatment dates that postdate the alleged injury by three months with no prior appointments. What should the adjuster do?
Answer: Flag the claim for SIU referral and request a chronological medical review
Unexplained gaps and billing anomalies are red flags warranting an SIU referral and thorough medical record review before any payment decision.
Which technology tool is most commonly used by insurance companies to detect claim fraud through pattern recognition across large datasets?
Answer: Predictive analytics and machine learning models
Predictive analytics and machine learning models analyze large claim datasets to identify anomalous patterns that may indicate fraud.