SIU Referral & Fraud Indicators Flashcards
7 cards from real CCP practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 SIU Referral & Fraud Indicators flashcards as text
A claimant reports a vehicle theft but the GPS data shows the vehicle was stationary at a different location than reported. What fraud indicator does this represent?
Answer: Physical evidence inconsistency
When physical or electronic evidence contradicts the claimant's account, it is a classic physical evidence inconsistency fraud indicator requiring SIU referral.
Which of the following is the MOST significant red flag when a medical provider submits bills for a claimant?
Answer: Billing for services on dates the claimant was hospitalized elsewhere
Billing for services rendered on dates when the patient was provably elsewhere indicates phantom billing fraud.
A newly purchased policy is followed within days by a large theft claim. This scenario most closely resembles which fraud scheme?
Answer: Policy inception fraud
Policy inception fraud occurs when a policy is obtained specifically to file an immediate fraudulent claim.
When an SIU investigation is opened, what obligation does the insurer generally have under most state regulations?
Answer: Report fraud findings to the state insurance fraud bureau within a specified timeframe
Most states mandate that insurers report suspected fraud to the state insurance fraud bureau or DOI within a specific period after discovery.
A claimant's recorded statement contains inconsistencies about how the accident occurred. Which action should the adjuster take FIRST?
Answer: Document the inconsistencies and consider an SIU referral
The adjuster should document all inconsistencies and evaluate whether they rise to the level requiring an SIU referral per company guidelines.
Which scenario is a typical indicator of a staged auto accident?
Answer: Multiple unrelated passengers in both vehicles who all claim injuries
A disproportionate number of injury claimants who are strangers to each other and to the vehicles is a hallmark of staged accident rings.
What is 'paper accident' fraud?
Answer: Reporting an accident that never occurred to collect insurance proceeds
A 'paper accident' is a fictitious collision that never happened, with all documentation fabricated to support the fraudulent claim.