AIC 48 Flashcards
Split limits
Separate limits for bodily injury and property damage liability coverage.
Umbrella liability policy
A liability policy that provides excess coverage above underlying policies and may also provide coverage not available in the underlying policies, subject to a self-insured retention.
Excess liability policy
A policy that covers liability claims in excess of the limits of an underlying policy or a stated retention period
lien
A creditor’s legal right or interest in another’s property, usually lasting until satisfaction of the specific debt or duty that the lien secures.
Subrogation
The process by which an insurer can, after it has paid a loss under the policy, recover the amount paid from any party (other than the insured) who caused the loss or is otherwise legally liable for the loss.
Cost shifting
The practice of charging higher fees to payment sources that impose fewer controls.
Three ways multiple coverages for BI claims may be identified
- When coverages apply under the same policy (e.g. med-pay and BI)
- When multiple coverages apply on different policies (e.g. workers comp and auto policy)
- When one insured has 2 policies from different insurers that cover the same loss (e.g. two personal auto policies with BI)
Interpolicy stacking v. Intrapolicy stacking
Interpolicy stacking: involves 2 or more separate policies, with which thel imit of one policy is added to (stacked on) the limit of the other policy)
Intrapolicy stacking: A single policy that covers more than one vehicle, with all limits stacked
Compare responsibilities of medical liens with Medicare liens
Medical liens: Hospitals, doctors, and other healthcare providers.
Medicare liens: must be reported when the auto policy is primary to Medicare.
In what government programs is property-casualty considered to be the primary payor and the program secondary?
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Subrogation
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Why do most patients not attempt to control or question their treatments?
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Compensatory damages
A payment awarded by a court to reimburse a victim for actual harm.
Special damages
A form of compensatory damages that awards a sum of money for specific, identifiable expenses associated with the injured person’s loss, such as medical expenses or lost wages.
Loss of earnings capacity
The reduction in a worker’s earning ability as a result of an injury.
General damages
A monetary award to compensate a victim for losses, such as pain and suffering, that does not involve specific, measurable expenses.
Loss of consortium
The loss of benefits that one spouse is entitled to receive from the other, including companionship, affection, and sexual relation resulting from the injury or death of a spouse.
Punitive damages (exemplary damages)
A payment awarded by a court to punish a defendant for a reckless, malicious, or deceitful act to deter similar conduct; the award need not bear any relation to a part’s actual damages.
Tangible loss v. intangible loss
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Two (2) types of assistance that can be compensable after an insured event
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How are general damages determined if settled by an insurer
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Five (5) different types of family members who might make a loss of consortium after BI to another family member
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Why do a court award punitive damages
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How does an injured person’s compensation for interest and fees differ between states?
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Utilization Review
A cost-containment method that evaluates the appropriateness of treatment in terms of necessity, frequency, and cost.
Medical bill audit
An analysis of the bills from healthcare providers to ensure that they bill for proper services and that the charges for these services are appropriate.
State fee schedule
A listing of fixed relative values for medical service and treatment that limits the amounts charges by healthcare providers. Services are measured in terms of number of units with a predetermined price per unit.
Usual, customary, and reasonable (UCR) charges
Charges for which physicians are reimbursed on the basis of their usual fee as long as the fee is reasonable and customary.
Hospital bill audit
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.
Retrospective review (peer review)
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.
Treatment guidelines
Common protocols for treatment or therapy that are developed using data provided by healthcare providers.
Palliative care
Care provided to relieve a patient’s pain
Restorative care
Care provided to restore a patient’s functional abilities.
Preadmission certification
A process for establishing preapproval for hospital admission or services (prospective review).
Fee-for-service (FFS) system
A payment arrangement under which a healthcare provider sets its fee and the insurer or patient pays the fee after the service is rendered.
Preferred provider organization (PPO)
An administrative organization that meets the common needs of healthcare providers and clients and that identifies networks of providers and contracts for their medical services at discounted rates.
Health maintenance organization (HMO)
An organization that provides all the care needed by its members in exchange for a fixed fee.
Concurrent review
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 order are being followed.
Discharge planning
The process of establishing a program for the type and amount of treatment after a patient is discharged from the hospital.
Independent medical examination (IME)
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.
Activity modification
An injury management technique for allowing patients to continue enough physical activity to avoid complete disability while maintaining a tolerable comfort level.
Return-to-work initiative
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.
Health Insurance Portability and Accountability Act (HIPAA)
Federal legislation establishing standards for health insurance information exchanges and health coverage protection when jobs are lost or changed.
Maximum medical improvement (MMI)
The point at which no further medical progress or recovery is expected.
Medical record
Any document that identifies a patient and describes the healthcare and services provided to that patient.
Medicolegal report
Any document, prepared for attorneys, claim reps, or industrial commission, that describes the patient’s injury, current physical and mental condition, and the expected outcome of the patient’s treatment.
Narrative report
A document prepared for healthcare providers to summarize the course of a patient’s treatment and state the diagnosis; usually accompanied by supporting documentation.
Ambulatory care records
Documents, prepared by centers providing outpatient surgical and diagnostic treatment, that include patient identification, history of illness or injury, physical findings, diagnostic and therapeutic orders, clinical observations, disposition of the patient, and follow-up care.
X-ray
An imaging tool that provides one-dimensional pictures of the comparative densities of the body; used to diagnose broken bones and other internal conditions.
Computerized tomography (CT) scan
A diagnostic imaging tool that takes a series of x-rays at various angles and converts resulting images into digital codes that a computer interprets and reproduces on a video screen. Used to diagnose problems of the brain and spine.
Myelography
A diagnostic imaging procedure in which a radio-opaque dye is injected into the spinal column so that x-rays can outline the spinal cord and nerves. This procedure detects herniated discs, tumors and inflammations in the spinal structure, and congenital deformities.
Magnetic Resonance Imaging (MRI)
A diagnostic imaging tool that uses a superconductive magnet, electromagnetic waves, and a sophisticated computer system to crease detailed images of the body’s interior.
Thermography
A diagnostic imaging procedure that measures the surface temperature of the skin, detecting injured areas.
Job modification
A change in a job’s physical demands, number of duties, emotional demands, and/or hours required.
Labor market survey
A formal study of job openings in a local community based on local employment listings, newspaper ads, and direct employer contracts.
Orthopedic surgeon
A medical doctor who performs surgery on bones, joints, and related supporting structures and prescribes medicine.
Registered nurse (RN)
A registered medical professional who specializes in hospital-based patient care.
Licensed practical nurse (LPN)
A licensed medical professional who specialized in hospital-based patient care.
Audiologist
A medical specialist who evaluates, diagnoses, and treats patients for hearing loss.
Certified orthotist
A certified specialist who evaluates the orthotic needs of patients, formulates the development and fitting of orthoses, and maintains patients’ orthotic records.
