Analysis of national data by Centers for Medicare and Medicaid Services (CMS) of Medicare insurance claims to locate the greatest risk of inappropriate program payment. This gathering of data is done to reduce the number of noncovered claims or unnecessary services. CMS provides its findings to the fiscal intermediaries who develop their review policies to identify abuse and overutilization of services.
Insurance Encyclopedia
Focused studies
State-required studies that examine a specific aspect of health care (such as prenatal care) for a defined point in time. These projects are usually based on information extracted from medical records or managed care organizations’ data (enrollment files, encounter or claims data). State staff, External Quality Review Organization (EQRO) staff, managed care organization (MCO) staff, or more than one of these entities may perform such studies at the discretion of the state.
FOIA
See: Freedom of Information Act (FOIA) .
Folded
An article folded in such a manner as to reduce its bulk 33-13% from its normal shipping cubage when not folded.
Follow the Fortunes
REINSURANCE: A clause in a reinsurance treaty whereby the reinsurer undertakes to follow the fortunes of the insurer. Thus, if the insurer settles a claim ex-gratia, the reinsurer may be expected not to deny liability for his share in the settlement.
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UK: a clause in reinsurance contracts under which the reinsurer is committed to following the decisions on claims made by the direct insurer.
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UK:A proportional reinsurance principle, not always stated in the policy, under which the reinsurer shares the same fate as the cedant in regard to the underwriting and contractual risks. It does not include the cedant’s commercial risk, i.e. total business risk or ex-gratia payments unless agreed or allowed under any relevant clause.
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A provision in reinsurance agreements, not always specifically identified as such, in which it is agreed that the reinsurer is bound to the same fate as the cedant with respect to risks covered.
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REINSURANCE: Follow the fortunes generally provides that a reinsurer must follow the underwriting fortunes of its reinsured and, therefore, is bound by the decisions of its reinsured in the absence of fraud, collusion or bad faith. It requires a reinsurer to accept a reinsured’s good faith, business-like reasonable decision that a particular risk is covered by the terms of the underlying policy. The term is often used interchangeably with follow the settlements, and there may be overlap between the affect of follow the fortunes and follow the settlements when the “risk” is what generated the loss. Follow the fortunes is focused on “risk” determination, not necessarily tied to a loss settlement.
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REFERENCE: See: “Reinsurance, Follow the Fortunes.”
Follow the Lead
A custom in an insurance market e.g., Lloyd’s whereby once a leading underwriter has accepted part of an insurance, other underwriters will tend to follow him.
Follow the settlements
A clause under which the reinsurer agrees to pay its share of the cedent’s settlements. The reinsurer is not normally obliged to pay if the reinsured is not liable under the policy or the loss is excluded under the treaty. The clause modifies the position by requiring the reinsurer to follow the settlement rather than the contract.
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REINSURANCE: Follow the settlements generally provides that a reinsurer must cover settlements made by the reinsured in a business-like manner, provided the settlement is arguably within the terms of the reinsured’s policy and the reinsurance agreement and the settlement is not affected by fraud, collusion or bad faith. It is an expectation that the reinsurer will abide by the reinsured’s good faith determination to settle, rather than litigate, claims under a reinsured policy and not re-litigate a reinsured’s settlements ceded to the reinsurance agreement. The term is often used interchangeably with follow the fortunes, and there may be overlap between the affect of follow the settlements and follow the fortunes when the “risk” is what generated the loss. Follow the settlements is focused on “loss settlement”, not necessarily tied to a “risk determination” arising out of follow the fortunes. Follow the settlements will not supersede the express terms and conditions of the reinsurance agreement.
Follow-up file
Reminder method used to track pending or resubmitted insurance claims and to telephone or send inquiries about nonpayment. Also called a suspense, tickler file , or tracing file . Also see tracing file or tickler file .
Follow-up medical-legal evaluation
In a workers’ compensation case, an evaluation done within 1 year following a comprehensive medical-legal examination performed by a qualified medical evaluator, agreed medical evaluator, or primary treating physician of the same injury or injuries.
Following Form
A term for a fire or other form written exactly under the same terms and coverage as other insurance on the same property.