Claims Management Flashcards
7 cards from real CPHRM practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Claims Management flashcards as text
In the context of healthcare claims, 'occurrence reporting' is BEST described as:
Answer: Notifying the insurer of events that may lead to a claim, even before one is filed
Occurrence reporting to insurers involves notifying them of incidents or events with claim potential before a formal claim is made, preserving coverage and enabling early investigation.
Which principle guides the concept that a healthcare provider owes a heightened standard of care to patients who are incapacitated or vulnerable?
Answer: Special relationship doctrine
The special relationship doctrine recognizes that certain relationships, such as provider-patient, impose heightened duties of care and protection.
A hospital settles a malpractice claim for $150,000. Under the National Practitioner Data Bank (NPDB) rules, this payment must be reported:
Answer: Within 30 days of the payment
NPDB regulations require that all medical malpractice payments made on behalf of a licensed healthcare practitioner be reported within 30 days.
Which alternative dispute resolution method uses a neutral third party who renders a binding decision?
Answer: Arbitration
Arbitration involves a neutral arbitrator who hears both sides and issues a binding decision, unlike mediation where the neutral only facilitates negotiation.
In a comparative negligence jurisdiction, a plaintiff found 40% at fault for their own injury can recover:
Answer: 60% of the total damages awarded
Under pure comparative negligence, a plaintiff's recovery is reduced by their percentage of fault, so 40% fault yields 60% of the total damages.
What is the function of a 'hammer clause' in a liability insurance policy?
Answer: It allows the insurer to limit its liability if the insured refuses a reasonable settlement
A hammer clause (or consent-to-settle clause) penalizes the insured by capping insurer liability at the rejected settlement amount if the insured refuses a reasonable offer.
Which metric is MOST useful for evaluating the effectiveness of a healthcare organization's claims management program over time?
Answer: Average claim cost and closure rate trends
Tracking average claim cost and closure rate trends reveals whether claims are being resolved efficiently and at lower financial impact over time.