Insurance reserves that are calculated using generally accepted accounting principles. Also see generally accepted accounting principles (GAAP) .

Provision in a managed care contract that either limits the amount of information that a health care provider may share with a patient or limits the situations in which a provider may recommend a certain alternative treatment when the plan does not cover it. This may be experimental treatments or treatment that may be expensive even if this might be the best course of action for the patient.

Amount of income that is in excess after benefit and administrative expenses have been accounted for.

Financial statement for insurance that shows underwriting and investment gains and losses for either an individual case, group of cases, or an entire category of group business.

Illegal or unethical attempt to manipulate a system for financial gain such as billing to maximize income by listing a principal diagnosis that puts the patient in the highest-priced diagnosis-related group (DRG) in a prospective payment system (PPS) when a lower-priced diagnosis more precisely depicts the services given for a patient’s medical problem.

1. Significant number of daily evaluation and management (E&M) visits by the same physician to multiple patients at a facility within a 24-hour period. When insurance claims reach the insurance carrier in this type of situation, it may result in medical review to determine medical necessity for the visits. 2. In Medicare fraud, to bill based on gang visits (e.g., a provider who visits a nursing facility and bills for 20 visits without furnishing any specific service to, or on behalf of, individual patients).

CPT codes that are not covered by the Medicare program; thus they do not have relative values under the resource-based relative value scale (RBRVS).