an agreement whereby insurance companies collect fees or "premiums" from individuals or companies on a regular basis. In return, they agree to pay for specific benefits.
any expense complete or partial payment is provided under the insurance policy.
an item covered by an insurance policy, or something paid to or on behalf of a recepient.
are studies that an insurance company uses.
Third Party Administrator
(TPA) a professional firm that is under contract to deal solely with adminstering the eligibility and claim payment services including all of the paperwork for self funded benefit plans.
what does HMO stand for?
health maintenance organization
Point of Service (POS)
These plans combine characteristics of HMO's and PPO's.
Departments in an Insurance Company
within each insurance company, there are a number of departments with varying responsibilities.
responsible for presenting insurance products to the company's customers.
responsible for ensuring that the company's operations are conducted on a mathematically sound basis.
Dept of Insurance
this dept holds for each state the primary legal authority over the operations of all insurance companies within that state.
defined as a denial or renunciation of responsibility.
Portability and accountability act of 1996
defined as deception to cause a person to give up property or something of lawful right.
involves the employees of the company against which the fraud is perpetrated. the employee may act alone or with another or other employees.
buying insurance or coverage for the purpose of making a profit.
an organized effort to discover the facts or truth of the matter.
Prompt, cautious contact with information sources is ESSENTIAL in every investigation.
Outside Sources of Fraud
These contacts involve the verification of dates, type of services rendered, and amounts charged to the patient.
the act of an employee illegally taking funds from a company they work for. this can be committed by anyone in a firm.
Embezzlement or Mismanagement
to provide minimal protection in case the problems with the records were found to conceal ----------------of funds.
are often the larger of the two awards and are intended primarily to punish wrongdoing by the defendant and make an example of them to help deter such actions in the future.
is defined as intentional conduct to cause injury or conduct
The dollar amount of a bad faith is based on two concepts:
1. the degree of the wrongfulness
2. the wealth of the defendant.