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TCR2 Final Review Flashcards

1
Q

If property damage claim is paid at 100%, does this mean we have to pay the bodily injury claim at 100%?

A

No

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2
Q

Acceptable reasons for overall bypass consultations

A

Opened in error

No coverage

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3
Q

Understand CBP for uninsured claims

A

CBP is the uninsured person/driver

Unknown person

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4
Q

Four criteria needed in CIQ for recommendation of pain and suffering

A

Diagnoses
Impact on lifestyle
Venue
Evaluation

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5
Q

Where do you enter your review of the medical records

A

Evaluation tab

Save to conduct page by clicking add to strategy

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6
Q

Submitted specials “other” category includes

A 
Childcare 
Housekeeping 
Mileage 
Transportation expenses 
Other expenses related to the claim
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7
Q

Bad faith claims can arise from

A

Failure to act fair, prompt and reasonable
Failure to inform of coverages
Failure to explain denial/disclaimer

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8
Q

Extra-contractual damages

A

Awarded against insurance companies for bad faith

Can include attorney fees, interest, costs, and consequential damages

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9
Q

What can occur if you increase your offers without justification?

A

Bad faith

Suggests that the first offer was not fair and reasonable

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10
Q

Where do most all states Unfair Claims Practice laws originate from?

A

Model Act

NAIC

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11
Q

What is a time limit demand?

A

Gives a specific amount of time to respond

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12
Q

What situations would an offer of policy limits be appropriate and what would you need to explain to the insured?

A

Obvious injury that exceeds limits

Advise insured of policy limits
Advise insured they can hire an attorney at their own expense
Advise insured they have the right to contribute to the claim

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13
Q

What are general damages

A

Inconvenience

Pain and suffering

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14
Q

What are special damages?

A

Out of pocket expenses

Have to be substantiated

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15
Q

How does GEICO determine the value of a claim?

A

Judgement and experience

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16
Q

When aggravated liability is involved, what should the insured be informed of?

A

Policy limits
Possibility of punitive damages
We typically do not pay punitive damages

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17
Q

Explain loss of consortium

A

Loss of sex, society or services
Spouse or dependent can claim
Derivative claim

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18
Q

Explain loss of earnings capacity

A

Difference of having to take a lower paying position due to injuries

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19
Q

Factors for claims of permanency

A 
Competent evidence for allegation of suffering 
Permanent injury 
AMA guidelines 
Testimony of treating physician
Physician's reputation
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20
Q

Factors for claims of scarring

A 
Future enjoyment of life
Does it affect the ability to work
Masking factors
Can scarring be improved through plastic surgery
Cosmetic value 
Age
Gender
Occupation 
Marital status
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21
Q

Examples of collateral source

A 
No fault coverage 
PIP/MedPay
Worker's Compensation 
Sick leave
Health insurance
22
Q

What is the release for UM/UIM?

A

Release in trust

23
Q

What is general release?

A

Release in full

Normal release

24
Q

Typical method providers use to document findings.

A

Subjective - patients complaints
Objective - examination/ findings
Assessment - diagnosis
Plan - treatment plan

25
ROS
Review of systems
26
MMI
Maximum medical improvement | State where condition cannot be improved or when treatment has plateaued
27
ADL
Activity of daily living Functional mobility Personal care Inability to do causes a self-care deficit
28
DTR
Deep Tissue Reflex Reflex hammer Test reflexes
29
Motion palpitations
Chiro uses hands to touch/feel the motion of specific segments of the spine while the patient moves
30
Osteoarthritis
Joint thinning
31
Spondylolisthesis
Forward displacement of vertebrae one over another
32
Stages of soft tissue injury
Acute inflammatory Repair Remodeling
33
Acute inflammatory phase
``` Pain Swelling Redness Warmth From time of impact to 72 hours Passive modalities ```
34
Repair phase
Beginning of active modalities
35
Remodeling phase
Shift from passive/active modalities to active modalities
36
Radiculopathy
Compression or irritation of a nerve as it exits the spinal column Conservative treatment Can resolve within 6 weeks to 3 months Most common in lumbar and cervical
37
Dermatomes
Area of skin mainly supplied by a single spinal nerve
38
Medicare is what type of lien?
Super lien
39
Desktop activities best practices
``` Complete what is due today first Create a plan of action Limit one activity per claim Avoid setting entries for Monday Follow appropriate time lines ```
40
What is the sole purpose of your action plan?
Move file toward closure
41
Phases of negotiation
Preparation Opening - build rapport before making initial offer Bargaining - goal is win-win Closing
42
Ways to approach a rejection of an offer
Ask injured party for a dollar figure they feel the claim is worth Ask why they should receive more Support your offer by going through the strengths/weaknesses Explain why the injured party demand is different/unrealistic/unwarranted Do not jump automatically or increase offer without justification
43
When is it appropriate to offer a first call settlement?
Treatment minimal | Unrepresented
44
When can you use oral releases?
Unrepresented Less than $5K 1st call settlement $1,000/$1,500 without medical documentation
45
When can you not use oral release?
``` Open-ended Modified Minor children Uninsured Under-insured Is attorney represented ```
46
CHO guidelines for 1st call settlement and early resolution
Treatment is minimal | 3 days within determining liability and discussing settlement
47
Define negotiation and what is the goal?
Confer with another so as to arrive at the settlement of some matter or to arrange for or bring about through conference discussion and compromise Means by which parties seek a settlement that is agreeable to each with the utmost of good faith and fair dealing Agreement not victory
48
Tools to help reduce BI on case life
Aggressive and thorough follow up Lack of interest process Follow proper HIPPA usage guidelines Online forms and e-signature
49
What is the lack of interest process?
Day 1-10 2 contact attempts and letter Day 10-20 2 contact attempts Day 20 Send LOI letter Day 35 Close
50
BI process
``` Injured claimant Treatment BI Process Obtain Authorization HIPPA Request Meds Evaluate and Settle ``` Under 5K - oral release Over 5K, Minors, UM/UIM - written release

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