Occur when the patient’s medical record contains evidence of a service that does not exist in the encounter data. This is the most common problem in partially or fully managed care capitated plans because the provider does not need to submit an encounter in order to receive payment for the service and therefore may have a weaker incentive to conform to data collection standards.

Occur when the encounter data contain evidence of a medical service that is not documented in the patient’s medical record. If we assume that the medical record contains complete information on the patient’s medical history, a false positive may be considered a fraudulent service. In a fully managed care capitated environment, however, the provider would receive no additional reimbursement for the submission of a false-positive encounter.

Federal law requires that covered employers must grant an eligible employee up to a total of 12 workweeks of unpaid leave during any 12-month period for one or more of the following reasons:• For the birth and care of the newborn child of the employee• For placement with the employee of a son or daughter for adoption or foster care• To care for an immediate family member (spouse, child, or parent) with a serious health condition• To take medical leave when the employee is unable to work because of a serious health condition

Rider or provision in a life insurance policy that provides term insurance coverage on the insured’s dependents (e.g., spouse, children).

1. Specific dollar amount that must be paid either monthly, quarterly, or annually by an individual, covered family member or a specified amount of time that must elapse before a medical insurance plan or government program begins covering health care costs. For the majority of plans, this amount must be incurred each calendar or fiscal year before insurance benefits will be reimbursed. 2. One deductible that when fulfilled relieves a family of satisfying a deductible for each individual family member.

Review of medical events in the patient’s family including diseases that may be hereditary or contagious and conditions that place the patient at risk. Documented review of two or all three past, family, and/or social history (PFSH) areas, depending on the category of evaluation and management (E/M) service that may be performed. All three areas are required for comprehensive assessments.

Special individual insurance policy that combines whole life insurance with decreasing term insurance. The whole life insurance part of the agreement is paid as a lump sum on the death of the insured. The decreasing term part of the policy gives an income for a predetermined period to assist in supporting the insured’s family.

Life insurance policy that combines whole life and decreasing term insurance. In this type of agreement, the beneficiary is paid during a specific period of time if the insured dies before the end of the period specified and in addition receives the face amount of the policy either at the end of the specified period or after death of the insured.

One life insurance contract that gives coverage to all members of a family. Generally this is whole life insurance on the wage earner, whole life or term insurance on the spouse, and smaller amounts of term insurance on the children including automatic insurance with no premium increase for children born after the policy is issued.

Under Medicare Secondary Payer guidelines, a person enrolled in a group health plan based on another person’s enrollment (e.g., spouse, adopted child, stepchild, parent, sibling).