Software program created by the Office of the Inspector General (OIG) that helps to access provider claims data and to limit the need for the OIG to send multiple requests to insurance carriers for claims information. It can assist in detection of aberrant billing practices of providers.

In workers’ compensation cases, a criterion for determining liability, or whether a claim is or is not compensable. AOE refers to how the activity of work led to the injury in question. It is one of the legal tests that must be met for a medical condition to be covered by workers’ compensation insurance. COE refers to how the activity the employee was engaged in at the time of injury must grow out, or be incidental to, the employment.

In the Medicare program, the average number of days for a patient’s DRG inpatient hospital stay. This figure is used to determine payment for outlier cases and to predict occupancy rates. To obtain this number, use this formula: total number of patient days divided by (÷) the total number of hospital admissions for a specific time period. It is also known as average length of stay (ALOS).

Disability occurring or aggravated while the patient is in military service.

Status of an insurance policy on which the monthly premiums have not been paid by a subscriber or member and are past due but which has a grace period that has not expired.

***

Overdue premiums.

Willful, deliberate, and malicious act of setting fire to property.

***

The intentional setting a fire of property. The illegal burning of a building or other property, the crime of setting fire to something.

***

UK: The criminal act of setting fire to property deliberately. The resultant damage is covered by a fire policy unless the insured is the arsonist.

***

The burning of a structure with intent to commit a felony. There are many types of arson but the only type the adjuster must be concerned with as a fraud is arson for profit. Most arson fires are not profit but are rather spite, revenge – or jealousy – inspired fires.

***

US: The willful and malicious burning of, or attempt to burn, any structure or other property, often with criminal or fraudulent intent.

1. See administrative simplification (AS). 2. HCPCS Level II modifier that may be used with CPT or HCPCS Level II codes indicating services of an assistant at surgery. Use of this modifier affects Medicare payment. 3. See assistant surgeon (AS).