Medicare Glossary

Medicare Insurance Leads has provided a glossary of Medicare insurance terms, for your reference to help your prospects stay abreast with current trends in the Medicare market. Our glossary defines terms in which your prospects may encounter when dealing with Medicare or health-care related issues. Medicare Insurance Leads provides an easy-to-use reference for you and your prospects to return to, if questions arise in the future. This comprehensive list contains all of the important terms relating to the Medicare market, to provide a solid direction for your Medicare leads. Please contact Medicare Insurance Leads if you have any questions related to the following terms.

1. Abuse - The agent practices policies that are not sound and consistent with the rules set resulting to irrelevant costs in the Medicare Program.
2. Accepted Referral - Referral that is considered by a Medicare agent.
3. Algorithm - Rules for solving a problem in a limited number of steps.
4. Audit - An evaluation of services done by a Medicare agent.
5. Audit (desk) – Audits done in the office of a Medicare agent.
6. Case - Investigations done if the Medicare agent is suspected of fraudulent activities.
7. Claim - Also called as bills and invoices of services given by a Medicare provider.
8. Collections - Money collected from reimbursements done by over payments regarding Medicare.
9. Cost Avoidance - Intervention that is done to avoid overpricing of Medicare.
10. Cost Report - Report required from agents of Medicare that is necessary to determining reimbursement rate.
11. Data Mining - A report of the analysis of plenty of data collected in databases. Used in management purposes.
12. Detection - Activities done to detect fraud in Medicare programs
13. Dollars recovered - Money that represents the total of amount of over payments received by the state.
14. Edits – Examination of claims that are reviewed by the Medicaid Management Information.
15. Enrollment - The process of signing up for a Medicare program by clients to providers.
16. Excluded Individuals or Entities - People who are not eligible to enroll for a Medicare program.
17. Excluded Parties List System - Data about people who are not allowed to sign up for Medicare program services.
18. Expenditure - The amount the state spends that is reported by them as well.
19. Fee-for-service - Traditional payment for services given to providers for certain services.
20. Fraud - An intentional act of a person in order for him or her or other to benefit by use of deception.
21. Fraud Investigation - Investigations done to detect fraudulent acts of Medicare Agents.
22. Hybrid Model - A structure which should be followed by bureaus and offices when it comes to Medicare programs.
23. Inappropriate Payment - Payment that should not have been made possible or incorrect amount under legally appropriated requirements.
24. Investigation - Gathered evidence to prove that a Medicare agent has committed a fraudulent act.
25. Involuntary Disenrollment - State actions that make a provider of Medicare unable to sell Medicare programs.
26. Judgment - Court ruling on determination of rights and services of parties given a particular case.
27. Managed Care - Customized health care that are related to prevention, primary and ancillary services.
28. Managed Care Oversight - Supervision of organizations to make sure they are complying with rules set by Medicare programs.
29. Medicaid Integrity - Prevention and Detection of fraudulent acts to make sure over payments are avoided.
30. Offset - Withholding of funds to make sure that over payments are recovered from providers.
31. Participating Provider - A person that is actively billing the Medicare program.
32. Prevention - To make sure that frauds are minimized or avoided by people.
33. Propriety Database - A database that is copyrighted and can only be accessed through a subscription.
34. Provider - The person who is responsible for providing services for Medicare program.
35. RAMS I - A surveillance system developed by a contractor.
36. Recipient - The person who is receiving benefits of a Medicare program.
37. Recovery - Money recovered from over payments by individuals in a Medicare program.
38. Referral - Data about the provider fraud that is passed to the Fraud control unit or other investigative agencies.
39. Sampling - Random selection of a part of the population.
40. Sanction - Penalty given to Medicare agents who committed fraud.
41. Settlement - An agreement of some sort between a Medicare agent and a client.
42. Standard Operating Procedure - Processes that should be done when a certain happening takes place.
43. Statistical Analysis - Examination of data to draw conclusions or hypothesis regarding a certain population based on a sample.
44. SURS I - The first type of SURS system which was developed in the late 70’s or early 80’s.
45. SURS II - A version of SURS I that is more updated.
46. SURS-Advanced - A version that is more advanced that the SURS I.
47. Terminated Provider - An agent who is terminated for committing a fraudulent act to a client.
48. Tip - Complaint coming from a person who thinks a Medicare agent has committed fraud to him or her or to other clients.
49. Total Recoveries - The total amount of money redeemed due to over payments.
50. Withdrawn Provider - An agent who has withdrawn from providing Medicare programs.

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