41 terms

MOD 1 Chapter 1

Guide to Health Claims Examining - Introduction to Technical and Legal Issues
is an agreement whereby companies collect fees or "premiums" from individuals or companies on a regular basis
paying a premium in order to continue coverage after the initial policy period has expired
Lapse in coverage
a break in continuous insurance coverage
Coverage expense
Any expense complete or partial payment is provided under the insurance policy
Accidental Death and Dismemberment Insurance
pays a benefit to the beneficiary in the event of the insured person's death by accidental means
Disability Insurance
covers and employee's salary, or a percentage of it, while the employee is on disability leave
Health Insurance
covers medical and hospital services. Such policies are sold as individual or group policies
Life Insurance
coverage on a person's life
the federal program established under Title XIX of the Social Security Act of 1965
the Federal Health Insurance Benefit Plan for the Aged and Disabled under Title XVIII of Public Law 89-97 of the Social Security Act
Worker's Compensation
a medical and disability reimbursement program that provides 100% medical coverage and a scheduled weekly disability benefit for job-related injuries
Individual Insurance
issued to insure the life or health of a named person or persons
Group Insurance
provides coverage for several people under one contract
Actuarial Statistics
studies that an insurance company uses
Third Party Administrator
professional firm that is under contract to deal solely with administering the eligibility and claim payment services for self-funded benefit plans
Human Resources Department
responsible for matters relating the company's employees
Marketing Department
responsible for presenting insurance products to the company's customers
Actuarial Department
responsible for ensuring that the company's operation are conducted on a mathematically sound basis
New Business Department
processes new business acquired by the company and Department also schedules physical examination for policies that require evidence of insurability
Premium Services Department
handles and processes all premium payments received
Underwriting Department
responsible for making sure that the premium rates are accurate and that claim payments do not exceed the amount assumed when the premium rates were calculated
Accounting Department
maintains the records to show if the company is being run in a profitable manner
Claims Department
the processing of claims in a correct and timely manner
Legal Department
makes sure that the company's operations comply with federal, state, and local laws and with the Department of Insurance regulations
Department of Insurance
entire insurance industry is overseen by a larger body
a denial or renunciation of responsibility
deception to cause a person to give up property or something of lawful right
Internal Fraud
which involves the employees of the company against which the fraud is perpetrated
External Fraud
involves people outside the company that it is directed against
Insurance Speculation
means buying insurance or coverage for the purpose of making a profit
an organized effort to discover the facts or truth of the matter
is the act of an employee illegally taking funds from a company they work for
Legal damages
are monetary awards above and beyond the benefits provided by the group plan
Compensatory Damages
are designed to compensate an insured for all of the actual losses or damages to make that person whole again
Punitive Damages
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
as intentional conduct to cause injury or conduct that is carried on with the conscious disregard of the rights of others
demand for a witness or a document to appear
Bad Faith Awards
The dollar amount based on two concepts: (1) the degree of wrongfulness and (2) the wealth of the defendant
Conventional insurance
an employer or individual purchases an insurance plan and agrees to pay premiums to the insurance company
HIPAA Portability
the ability to transfer insurance companies and still be covered for pre-exisiting conditions
HIPAA Accountability
generally dealing with the patient's right to privacy from the medical provider, health insurer, and any other parties required in the healthcare process