IC36 Mock Test Sample 15
Third Party Administrators (TPAs) are required to follow a strict code of conduct, ensuring transparency, ethical practices, and proper assistance to policyholders during claim settlement. Clinical audits help assess the quality and appropriateness of healthcare services through structured guidelines and standardized review processes. Fraud prevention mechanisms such as red alert surveillance, investigations, and fraud triggers support efficient claims management. Provider management focuses on improving operational efficiency, negotiating tariffs, and enhancing service quality. Case management programs assist patients with chronic and complex conditions. Understanding medical conditions, healthcare classifications, and regulatory requirements contributes to effective health insurance administration and better customer outcomes.
Q1. The Third Party Administrators have to follow a code of conduct that may include:
a) Disclosure of license details and services to policyholders
b) Reporting material facts to the insurance company
c) Obtaining claim-related documents for settlement
d) Rendering assistance in complying with claim documentation
Q2. Which of the following is the odd one out among the tools required for Clinical Audit?
a) Structured treatment outlines for diseases
b) Educational guidelines for medical providers
c) Standard proforma for audit findings
d) Standard format of clinical interventions
Q3. Suitable _________ need to be devised at various places to filter claims at each level.
a) Fraud Triggers
b) Fraud Checkers
c) Fraud Indicators
d) Fraud Detectors
Q4. Mohit, who is overweight and has impaired glucose tolerance, is most likely suffering from:
a) Folliculitis
b) Cellulitis
c) Pyelonephritis
d) Diabetes Mellitus (Non-Insulin Dependent)
Q5. The TPA call centre operating 24×7 provides information regarding:
a) Coverage and benefits under the policy
b) Market comparison of insurance products
c) Negotiation of package rates
d) Pre-agreed schedule of rates
Q6. Red Alert Surveillance mechanisms help to:
a) Save time
b) Reduce manual intervention
c) Focus investigation efforts
d) Improve claim processing efficiency
Q7. Nimisha, hospitalized for pregnancy-related treatment, would generally receive:
a) Routine Care
b) Primary Care
c) Secondary Care
d) Tertiary Care
Q8. Case Management uses professionals such as:
a) Doctors
b) Counsellors
c) Public Health Professionals
d) Family Physicians
Q9. Case Management approaches have commonly been offered to clients with:
a) HIV/AIDS
b) Mental illness
c) Memory loss conditions
d) Physical disabilities
Q10. Growth of health insurance in India has been facilitated by:
a) Expansion of insurance companies
b) Improved healthcare infrastructure
c) Lifestyle-related demand for insurance
d) Introduction of new products
Q11. Which measure can help reduce fraud within the insurance industry?
a) Creating a common provider list
b) Pursuing criminal proceedings against offenders
c) Conducting annual inspections
d) Strengthening investigation practices
Q12. Which investigation is NOT specific to the nervous system?
a) CT Scan
b) MRI
c) Cerebral Angiogram
d) ERCP
Q13. A Cashless Authorisation Form generally contains:
a) Diagnosis details
b) Treatment information
c) Name of the treating doctor
d) Estimated duration of hospitalization
Q14. Clinical Audit may be conducted in tonsil surgery cases to:
a) Assess treatment appropriateness
b) Review medical expenses
c) Perform quality checks through sampling
d) Evaluate adherence to protocols
Q15. _____________ involves a deliberate attempt to defraud the insurer.
a) Internal Fraud
b) External Fraud
c) Soft Fraud
d) Hard Fraud
Q16. Prominent swollen veins under the skin are commonly associated with disorders of the:
a) Digestive System
b) Urinary System
c) Reproductive System
d) Circulatory System
Q17. The license issued to a TPA should generally be renewed within:
a) 1 day
b) 15 days
c) 30 days
d) 45 days
Q18. Provider Management aims at:
a) Building efficient operational processes
b) Negotiating better tariffs
c) Easing administrative interactions
d) Enhancing service effectiveness
Q19. Extending the length of hospital stay unnecessarily after surgery is an example of:
a) False claim by the patient
b) Escalated claim by the patient
c) Fraud by the hospital
d) Abuse by the hospital
Q20. Identify the odd one out among the following related to Haemorrhoids treatment:
a) Haemorrhoidectomy
b) Sclerotherapy
c) Cryosurgery
d) Neuropathy
