Term
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Definition
| Any deliberate deception committed against an insurer or an insurance producer for the purpose of unwarranted financial gain |
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Term
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Definition
| Exaggerating losses from a real accident and taking advantage of insurance benefits |
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Term
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Definition
Doctors' role of referring patients to clinics in which the doctors have an economic interest...
Form of provider abuse |
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Term
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Definition
| The practice of charging higher fees to payment sources that impose fewer controls |
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Term
| Injury Claim Management Equation |
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Definition
| The basis on which injury claims are managed: Price of Service X Use of service = Total Cost of healthcare services |
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Term
| Utilization Review (UR's) |
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Definition
| A cost-contaiment method that evaluates the appropriateness of treatment in terms of necessity, frequency, and cost |
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Term
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Definition
| An analysis of the bills from healthcare providers to ensure that they will bill for proper services and that the charges for these services are appropriate |
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Term
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Definition
| A listng of fixed relative values for medical service and treatments that limits the amounts charged by healthcare providers. Services are measured in terms of number of units, with a predetermined price per unit |
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Term
| Usual, Reasonable, and Customary (URC) Charges |
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Definition
Charges in which physicians are reimbursed on the basis of their usual fee as long as the fee is reasonable and customary...
This standard is not written into the P&C insurance contracts. |
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Term
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Definition
An analysis of services ordered by the doctor, services actually performed by the hospital, and services billed by the hospital to ensure the appropriateness of hospital charges...
Typically produce savings of 5-10% |
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Term
| Retrospective Reviews (Peer Review) |
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Definition
The review of a medical provider's records by another medical provider who practices in a similar discipline. Alternatively referred to as a records review...
Bases review on what is documented in the claim file |
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Term
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Definition
Common protocols for treatment or therapy that are developed using data provided by healthcare providers...
Also referred to as treatment protocols |
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Term
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Definition
| Care provided to relieve a patient's pain |
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Term
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Definition
| Care provided to restore a patient's functional abilities |
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Term
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Definition
| An approach to managing bodily injury claims before treatment occurs using preadmission certification, preadmission testing, fee arrangements, PPOs, and HMOs |
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Term
| Preadmission Certification |
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Definition
| A process for establishing preapproval for hospital admission or services |
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Term
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Definition
| A process of administering diagnostic tests on an outpatient basis before a patient is admitted to a hospital for surgery |
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Term
| Fee-for-Service (FFS) System |
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Definition
| A payment arrangement under which a healthcare provider sets its fee and the insurer or patient pays the fee after the service is rendered |
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Term
| Preferred Provider Organization (PPO) |
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Definition
| An administrative organization that meets the common need of healthcare providers and clients and that identifies networks of providers and contracts for their medical services at discounted rates |
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Term
| Health Maintenance Organization (HMO) |
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Definition
| An organization that provides all the care needed by its members in exchange for a fixed fee |
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Term
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Definition
| A direct intervention technique for monitoring the appropriateness of inpatient services and the length of a hospital stay and for determining whether a doctor's orders are being followed |
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Term
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Definition
| The process of establishing a program for the type and amount of treatment after a patient is discharged from the hospital |
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Term
| Independent Medical Exam (IME) |
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Definition
| A direct intervention technique that includes a brief review of the patient's history and treatment and a physical examination of the patient. Insurers use this technique in disputed claims for determining causation, current physical impairment, and the need for present or future treatment |
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Term
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Definition
| An injury management technique for allowing patients to continue enough physical activity to avoid complete disability while maintaining a tolerable comfort level |
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Term
| Return-to-Work Initiative |
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Definition
| A program with which the patient, the doctor, the patient's employer, and the insurer all try to help the patient recover and return to work |
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Term
| Managed Care Organization (MCO) |
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Definition
| A company that does not provide medical care but contracts with a medical network to provide treatment for members and coordinate the medical aspects of workers' compensation claims with employers, providers, or insurers |
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