CIFI flashcards
CIFI · Build recall with a focused review session.
32 cards. Read the term and the definition here. The deck at the top of this page is optional.
- Red flag
- A red flag is a claim feature that deviates from expected patterns and warrants review; it is an indicator, not proof of fraud.
- Staged accident indicator
- Indicators include abrupt braking, multiple occupants, prior damage, and rapid attorney or medical solicitation; these suggest possible staged collision fraud.
- Arson indicator
- Financial distress, multiple origin points, accelerant evidence, removed valuables, and forced entry inconsistent with the loss can suggest arson; each requires corroboration.
- Medical upcoding
- Upcoding is billing a higher-cost service or code than documented; it is detected by comparing bills with medical records and treatment notes.
- Premium fraud indicator
- Understated payroll, misclassified workers, undisclosed owners, and fake certificates of insurance are premium fraud indicators; verify with audits and third-party data.
- Anomaly detection
- Anomaly detection uses statistical models to score claims against peer baselines; a high score triggers review but does not alone prove fraud.
- Workers comp red flag
- Monday injuries, no witnesses, inconsistent physical ability, and prior similar claims are workers' compensation red flags; corroborate with records and surveillance.
- Chain of custody
- Chain of custody documents each transfer and storage of evidence; gaps can weaken admissibility and reduce the evidence's weight in fraud proceedings.
- Recorded statement
- A recorded statement is a claimant interview preserved by audio or video; obtain consent, verify identity, and note corrections to support later comparison.
- Examination under oath
- An EUO is a sworn policy-condition interview; questions may cover coverage and material misrepresentations, and the transcript can be used in litigation.
- Scene documentation
- Document the loss scene before alteration using photographs, measurements, and origin analysis; preserve samples and note who handled each item.
- Surveillance limits
- Surveillance should be lawful public observation; document date, time, and activity, and avoid trespass, harassment, or discriminatory targeting that could taint evidence.
- Medical bill review
- Compare itemized bills with records for services not rendered, unbundling, and excessive frequency; a qualified reviewer should interpret clinical necessity.
- SIU referral
- Refer a claim to SIU when indicators meet defined thresholds; the referral should state facts, evidence, and suspected scheme without conclusory accusations.
- Deterrence certainty
- Deterrence increases when offenders perceive a high certainty of detection and response; speed and severity of sanctions also affect the perceived cost.
- Anti-fraud plan
- An anti-fraud plan is a written program covering detection, investigation, reporting, training, and monitoring; some states require insurers to maintain one.
- Data sharing deterrence
- Sharing verified fraud data with industry databases and state bureaus raises detection risk; use accurate reports and comply with privacy and immunity laws.
- Frontline red flag training
- Training staff to recognize and refer red flags increases early detection; training should cover scheme types, documentation, and escalation paths.
- Deterrence metrics
- Track referral rate, confirmed fraud rate, recovery rate, and cycle time; these metrics show whether anti-fraud controls change behavior and outcomes.
- Vendor screening
- Screening vendors and providers for exclusions, ownership links, and adverse history reduces opportunity for collusive fraud before claims are paid.
- Conflict of interest
- A conflict exists when a relationship could impair impartiality; disclose it and recuse when the conflict materially affects judgment or appears improper.
- Confidentiality duty
- Investigators should share claimant data only with authorized persons who need it; protect identifiers and follow legal process for external releases.
- Evidence integrity
- Never alter, fabricate, or destroy evidence; document collection contemporaneously and preserve original files so findings can be independently verified.
- Interview coercion
- Threats, false imprisonment, and deceptive promises can invalidate statements and create liability; interviews must stay within legal and ethical limits.
- Fact versus inference
- Reports should separate verified facts from inferences and state the basis for each conclusion; correct errors promptly to maintain accuracy.
- Professional competence
- Investigators must know applicable law, methods, and scheme patterns, and recognize when to seek expert or legal assistance beyond their competence.
- Fraud elements
- Common fraud elements include a false statement, materiality, knowledge or intent, reliance, and damages; exact statutory elements vary by jurisdiction.
- Material misrepresentation
- A material misrepresentation is a false statement that would affect an insurer's decision; depending on law and policy, it may void coverage or support denial.
- Reservation of rights
- A reservation of rights letter preserves an insurer's coverage defenses while investigation continues; it helps avoid waiver of those defenses.
- Bad faith risk
- Suspecting fraud does not excuse unreasonable delay or a cursory investigation; insurers must investigate covered claims promptly and document decisions.
- Good faith immunity
- Many statutes give qualified immunity for reporting suspected fraud in good faith; immunity generally does not protect knowingly false or malicious reports.
- Policy conditions
- Notice, proof of loss, cooperation, and EUO are common policy conditions; material breach can prejudice coverage, but prejudice rules vary by state.