Medical Claims and Healthcare Coverage Flashcards
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Read the first 7 Medical Claims and Healthcare Coverage flashcards as text
When reviewing a claimant's medical records, an adjuster should pay particular attention to:
Answer: Gaps in treatment, pre-existing conditions, and the link between treatment and the claim event
Gaps in treatment may suggest the injury was minor, pre-existing conditions affect causation analysis, and treatment consistency with the claimed injury validates the claim's legitimacy and scope.
What is 'medical cost containment' in claims management?
Answer: Strategies and programs to ensure medical expenses are reasonable, necessary, and properly billed
Medical cost containment encompasses utilization review, bill auditing, preferred provider networks, and similar strategies designed to ensure appropriate and cost-effective medical care is delivered and billed correctly.
In the context of bodily injury claims, 'pain and suffering' damages represent:
Answer: Non-economic damages for physical pain, emotional distress, and reduced quality of life
Pain and suffering are non-economic general damages compensating claimants for the physical and emotional impact of injuries beyond objectively measurable financial losses such as medical bills or lost wages.
What is an ERISA lien in the context of personal injury claims?
Answer: A claim by an employer-sponsored health plan to recover benefits paid for injury-related treatment from a settlement
ERISA (Employee Retirement Income Security Act) liens allow employer-sponsored health plans to seek reimbursement from personal injury settlements for medical benefits they paid on behalf of the injured employee.
What does 'subrogation' mean specifically in the context of medical claims?
Answer: The insurer's right to pursue recovery from a responsible third party after paying medical benefits
Subrogation allows an insurer that paid medical benefits to stand in the claimant's place and seek reimbursement from the at-fault third party or their insurer for amounts already paid.
When evaluating future medical expenses in a serious injury claim, which factor is most important?
Answer: The nature of the injury and evidence-based projections of future treatment needs and associated costs
Future medical expense projections must be grounded in medical evidence about the injury's long-term impact, supported by expert opinions and life care plans documenting anticipated future treatment needs.
A 'structured settlement' in a medical injury claim is best described as:
Answer: Periodic tax-free payments made over time rather than a single lump sum, often used in serious injury cases
Structured settlements provide a stream of tax-free periodic payments over a defined period, which can better address ongoing medical expenses and living costs for seriously injured claimants than a single lump sum.