Investigation of an insurance applicant’s data that is carried out by the insurance company after insurance coverage was already given. It is an illegal practice and may be triggered by medical bills that reach threshold costs.

Directional term from back to front. Also referred to as posterior anterior (PA). Some x-rays are taken in this direction.

Date a fee entry or adjustment entry is inserted on a patient’s financial account by the bookkeeper of the provider or facility. This may not be the same date as the actual date of service but may occur within 5 days of the actual date of service.

Pertaining to the period of time after surgery. It begins with the patient’s emergence from anesthesia and continues through the time required for the acute effects of the anesthetic and surgical procedures to abate.

Evaluation of an insurance claim after a determination and after payment has been made to the provider or beneficiary.

Period of time between a medical service provided and a provider’s transmitted claim to the payer.

Case developed after the program safeguard contractor (PSC) has substantiated an allegation of fraud.

Maximum anticipated total payments (based on the most recent year’s utilization and experience and any current or anticipated factors that may affect payment amounts) that could be received if use or costs of referral services were low enough. These payments include amounts paid for services furnished or referred by the physician/group, plus amounts paid for administrative costs. Payments not included in potential payments include bonuses or other compensation not based on referrals (e.g., bonuses based on patient satisfaction or other quality of care factors).