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tcr2 school > TCR2 Final Review > Flashcards

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
Q

ROS

A

Review of systems

26
Q

MMI

A

Maximum medical improvement

State where condition cannot be improved or when treatment has plateaued

27
Q

ADL

A

Activity of daily living
Functional mobility
Personal care
Inability to do causes a self-care deficit

28
Q

DTR

A

Deep Tissue Reflex
Reflex hammer
Test reflexes

29
Q

Motion palpitations

A

Chiro uses hands to touch/feel the motion of specific segments of the spine while the patient moves

30
Q

Osteoarthritis

A

Joint thinning

31
Q

Spondylolisthesis

A

Forward displacement of vertebrae one over another

32
Q

Stages of soft tissue injury

A

Acute inflammatory
Repair
Remodeling

33
Q

Acute inflammatory phase

A 
Pain
Swelling 
Redness 
Warmth
From time of impact to 72 hours 
Passive modalities
34
Q

Repair phase

A

Beginning of active modalities

35
Q

Remodeling phase

A

Shift from passive/active modalities to active modalities

36
Q

Radiculopathy

A

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
Q

Dermatomes

A

Area of skin mainly supplied by a single spinal nerve

38
Q

Medicare is what type of lien?

A

Super lien

39
Q

Desktop activities best practices

A 
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
Q

What is the sole purpose of your action plan?

A

Move file toward closure

41
Q

Phases of negotiation

A

Preparation
Opening - build rapport before making initial offer
Bargaining - goal is win-win
Closing

42
Q

Ways to approach a rejection of an offer

A

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
Q

When is it appropriate to offer a first call settlement?

A

Treatment minimal

Unrepresented

44
Q

When can you use oral releases?

A

Unrepresented
Less than $5K
1st call settlement
$1,000/$1,500 without medical documentation

45
Q

When can you not use oral release?

A 
Open-ended 
Modified 
Minor children 
Uninsured 
Under-insured 
Is attorney represented
46
Q

CHO guidelines for 1st call settlement and early resolution

A

Treatment is minimal

3 days within determining liability and discussing settlement

47
Q

Define negotiation and what is the goal?

A

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
Q

Tools to help reduce BI on case life

A

Aggressive and thorough follow up
Lack of interest process
Follow proper HIPPA usage guidelines
Online forms and e-signature

49
Q

What is the lack of interest process?

A

Day 1-10
2 contact attempts and letter

Day 10-20
2 contact attempts

Day 20
Send LOI letter

Day 35
Close

50
Q

BI process

A 
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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