IC36 Mock Test Sample 19
Health insurance claim management involves claim registration, document verification, billing review, coding, auditing, and fraud detection to ensure fair settlement of claims. TPAs play a key role in provider networking, cashless services, customer support, and claims administration while adhering to IRDA regulations. Audits such as concurrent, process, and clinical audits help improve quality and identify irregularities. Fraud prevention relies on investigations, evidence, due diligence, and monitoring mechanisms. Provider management begins with empanelment and tariff verification. Effective case management focuses on achieving quality, cost-effective outcomes and restoring patient well-being while maintaining transparency and compliance.
Q1. Which audit is commonly used by insurers and TPAs to detect frauds?
a) Annual Audit
b) Periodic Audit
c) Concurrent Audit
d) Process Audit
Q2. What is generally revised based on the estimated amount of a claim?
a) Premium
b) Reserve
c) Tariff
d) Sum Insured
Q3. Which service is NOT generally expected from a TPA?
a) Provider Networking Services
b) Call Centre Services
c) Cashless Access Services
d) Selling insurance policies
Q4. Every investigation and verification should conclude with:
a) Proper Report
b) Settlement Voucher
c) Premium Receipt
d) Renewal Notice
Q5. Concurrent Audit strengthens cashless authorization by:
a) Reviewing historic data only
b) Negotiating premiums
c) Asking relevant questions before approval
d) Marketing insurance products
Q6. Fraudulent claims are generally repudiated based on:
a) Investigation Report
b) Hospital Bill
c) Proposal Form
d) Premium Receipt
Q7. Provider management starts with due diligence during:
a) Auditing
b) Networking
c) Empanelment
d) Coding
Q8. Manipulating documents for monetary gain is considered:
a) Abuse
b) Negligence
c) Fraud
d) Oversight
Q9. After claim registration, the next major step is:
a) Policy Renewal
b) Verification of Documents
c) Underwriting
d) Marketing
Q10. Skilled manpower in TPAs should be capable of:
a) Advertising
b) Selling policies
c) Analysing tariffs
d) Recruiting agents
Q11. Fraud is generally committed with the intention of obtaining:
a) Partial Benefits
b) Unauthorised Benefits
c) Automatic Benefits
d) Guaranteed Benefits
Q12. Which audit requires extensive patient-care data during treatment?
a) Infrastructure Audit
b) File Audit
c) Concurrent Audit
d) Retrospective Audit
Q13. Inflated and unnecessary claims lead to:
a) Reduced healthcare costs
b) Increased payer-funded healthcare costs
c) Elimination of fraud
d) Faster settlements
Q14. TPAs should refrain from:
a) Trading insurance records
b) Protecting confidentiality
c) Assisting claimants
d) Maintaining records
Q15. Which factor contributes to insurance fraud?
a) Public attitude
b) Insufficient penalties
c) Easy claim settlement practices
d) All of the above
Q16. Which step follows the capturing of billing information?
a) Registration of Claim
b) Coding of Claims
c) Claim Intimation
d) Policy Issuance
Q17. Once renewed, a TPA licence remains valid for:
a) 1 year
b) 2 years
c) 3 years
d) 5 years
Q18. Case Management ultimately aims to:
a) Increase claim frequency
b) Promote quality and cost-effective outcomes
c) Reduce staffing needs
d) Enhance marketing efforts
Q19. Which document checklist is used during claim scrutiny?
a) Prospectus
b) Processing Documentation
c) Share Certificate
d) Premium Ledger
Q20. Which activity is essential in fraud investigations?
a) Ignoring evidence
b) Proper documentation and proof
c) Immediate settlement
d) Premium adjustment
