Healthcare Compliance Glossary

Introduction

Healthcare compliance is a critical aspect of the healthcare industry, ensuring that organizations adhere to a complex web of laws, regulations, guidelines, and ethical standards. This glossary serves as a comprehensive resource for understanding key terminology related to healthcare compliance, designed to be informative and SEO-optimized for professionals and stakeholders in the field.

What is Healthcare Compliance?

Healthcare compliance refers to the process by which healthcare organizations, providers, and professionals ensure they are meeting the legal, ethical, and professional standards set forth by various regulatory bodies. This includes adherence to laws concerning patient privacy, billing practices, fraud prevention, quality of care, and more. The goal of compliance is to protect patients, maintain the integrity of the healthcare system, and avoid legal penalties.

Key Healthcare Compliance Terms (A-Z)

A

Accounting and Auditing Enforcement Releases (AAER) refer to financial reporting-related enforcement actions concerning civil lawsuits brought by the Commission in federal court, as well as notices and orders regarding the institution and/or settlement of administrative proceedings [1].

An Accountable Care Organization (ACO) is a voluntary group of physicians, hospitals, and other healthcare providers that assumes responsibility for the care of a defined population of Medicare beneficiaries. These beneficiaries are attributed to the ACO based on their utilization of primary care services [1].

Accreditation is an evaluative process where a healthcare organization undergoes an examination of its policies, procedures, and performance by an external accrediting body. This ensures that the organization meets predetermined criteria and typically involves both on-site and off-site surveys [3]. The Accreditation Cycle for M+C Deeming refers to the duration of CMS\'s recognition of an accrediting organization\'s determination that a Medicare + Choice organization (M+CO) is "fully accredited" [3].

Adjusted Average per Capita Cost (AAPCC) is CMS/HCFA’s best estimate for the amount of money it costs to care for Medicare recipients under fee-for-services Medicare in a given area. The AAPCC is made up of 142 different rate cells; 140 of them are factored for age, sex, Medicaid eligibility, Institutional status, working ages, and whether a person has both Part A and Part B of Medicare. The 2 remaining cells are for individuals with end stage renal disease [1].

Adjusted Community Rate (ACR): Under the ACA, insurers can\'t raise premiums based on health status, medical claims, gender, or most of the other factors that they had previously used to determine rates prior to ACA implementation [1].

Affiliated Covered Entity (ACE): Under HIPAA, legally separate covered entities under common ownership or control have an option to be treated as a single legal entity by choosing to designate as ACE. This enables the entities to share information in a way that would otherwise be impermissible (use vs. disclosure) [1, 2].

Agency for Healthcare Research and Quality (AHRQ): Agency within the Department of Health and Human Services, whose mission is to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable, and to work within HHS and other partners to make sure that the evidence is understood and used [1].

American Recovery and Reinvestment Act of 2009 (ARRA): Commonly referred to as the Stimulus Package, ARRA aims to create and maintain jobs, spur economic activity and long-term growth, and foster accountability and transparency in government spending through tax incentives, entitlement programs, and funding federal contracts, grants, and loans [1].

Annual Contractor Evaluation Report (ACER): CMS\'s Health Care Finance Administration’s formal evaluation report of Medicare contractor’s performance for the fiscal year. It is based upon results of the Contractor Performance Evaluation Program (CPEP) reviews, along with results of other special evaluations which are considered when evaluating contractor performance [1].

Anti-Kickback Statute (AKS): Federal criminal statute that prohibits the exchange (or offer to exchange) of anything of value, in an effort to induce (or reward) the referral of federal health care program business [1].

Abuse: A range of improper behaviors or billing practices including, but not limited to: billing for a non-covered service; misusing codes on the claim (i.e., the way the service is coded on the claim does not comply with national or local coding guidelines or is not billed as rendered); or inappropriately allocating costs on a cost report [3].

Access: (Privacy and Breach Notification Rules) The means used to retrieve, view, hear, read, write, modify, or communicate information, including records, data, or other system information [4]. (Security Rule) The ability or the means necessary to read, write, modify, or communicate data/information or otherwise use any system resource [4].

Administrative Safeguards: Administrative actions and policies and procedures that manage the selection, development, implementation, and maintenance of security measures. These measures protect electronic protected health information and create guidelines for its protection by employees [4].

Administrative Tribunal: An officially appointed or elected individual, judge, or group of individuals or judges, including those appointed by administrative agencies, who conduct hearings and exercise judgment over specific issues [4].

Agent: An agent of an organization is determined in accordance with the federal common law of agency. The organization is liable for the acts of its agents. An agency relationship exists if the organization has the right or authority to control the agent’s conduct in the course of performing a service on behalf of the organization [4].

Alternative Communications: Information or communications delivered to patients in a manner different than the organization’s normal practice. For example, patients may ask for delivery at an alternative address, phone number, or post office box [4].

Amend/Amendment: The correction of Protected Health Information (PHI) or the addition of PHI to an existing designated record set [4].

Authentication: The verification of a user, process, or device to allow access to resources in an electronic information system [4].

Authorization: An individual’s written statement of agreement to the use or disclosure of protected health information [4].

Availability: The property that data or information is accessible and usable upon demand by an authorized person [4].

B

Bankruptcy denotes the legal status of a person or entity that cannot repay the debts it owes to creditors [1].

Benchmarking involves the measurement of performance against established “best practice” standards [1].

C

CAN-SPAM Act: A law enacted in 2003 that establishes rules for commercial email, sets requirements for commercial messages, grants recipients the right to stop receiving emails, and outlines penalties for violations [1].

Centers for Medicare & Medicaid Services (CMS): Formerly known as the Health Care Financing Administration (HCFA), this agency within the Department of Health and Human Services administers the Medicare and Medicaid Programs [1].

Civilian Health and Medical Program of the Uniformed Services (CHAMPUS): A federal program that provides healthcare coverage to families of military personnel and other eligible individuals [1].

Clinical Laboratory Improvement Amendments (CLIA): Federal regulations that include standards applicable to all U.S. facilities or sites that test human specimens for health assessment or to diagnose, prevent, or treat disease [1].

Commission of Sponsoring Organizations (COSO): A joint initiative of five private sector organizations dedicated to providing thought leadership through the development of frameworks and guidance on enterprise risk management, internal control, and fraud deterrence [1].

Conflict of Interest (COI): Occurs when an individual’s private interest interferes, or appears to interfere, with the interests of the corporation as a whole. This can arise when an employee, officer, or director takes action or has interests that may make it difficult to perform their company work objectively and effectively [1].

Consolidated Omnibus Budget Reconciliation Act (COBRA): Continuation health coverage legislation that gives employees and families who lose health benefits the right to choose to continue group health benefits provided by their group health plan for limited periods of time under certain circumstances [1].

Consumer Assessment of Health Plan Survey (CAHPS): A federal government initiative for Medicare & Medicaid aimed at developing satisfaction surveys based on standardized items, supplemented by additional targeted elements to make the surveys both adaptable to different sub-populations and suitable for making some cross-group comparisons [1].

D

Department of Health & Human Services (DHS): The U.S. government’s principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves. Also referred to as HHS [1].

Department of Justice (DOJ): Works to enforce federal law, seek just punishment for the guilty, and ensure the fair and impartial administration of justice through its various agencies [1].

Designated Health Services (Stark Law) (DHS): Under the Stark Law, these services include clinical laboratory services; physical therapy, occupational therapy, and outpatient speech-language pathology services; radiology and certain other imaging services; radiation therapy services and supplies; durable medical equipment and supplies; parenteral and enteral nutrients, equipment, and supplies; prosthetics, orthotics, and prosthetic devices and supplies; home health services; outpatient prescription drugs; and inpatient and outpatient hospital services. The term DHS specifically refers to services payable, in whole or in part, by Medicare, and generally excludes services reimbursed by Medicare as part of a composite rate, unless those services are explicitly listed as DHS [1].

Drug Supply Chain Security Act (DSCSA): Outlines critical steps to build an electronic, interoperable system to identify and trace certain prescription drugs as they are distributed in the United States, identify illegitimate drugs, and facilitate recalls [1].

Durable Medical Equipment (DME): Medical equipment owned or rented which is placed in the home of an insured to facilitate treatment and/or rehabilitation. DME generally consists of items which can withstand repeated use, are primarily and customarily used for a medical purpose, and are usually not useful to a person in the absence of illness or injury [1].

Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS): An industry that sells or rents certain medical equipment [1].

Conclusion

Understanding the terminology presented in this glossary is fundamental for anyone navigating the complexities of healthcare compliance. By familiarizing themselves with these terms, healthcare professionals and organizations can better ensure adherence to regulations, protect patient data, and uphold ethical standards in the delivery of care. This ongoing commitment to compliance is vital for maintaining trust, avoiding legal repercussions, and ultimately contributing to a safer and more effective healthcare system.

References

[1] HCCA. (n.d.). Compliance Dictionary. Health Care Compliance Association. Retrieved from https://www.hcca-info.org/publications/healthcare-compliance-resources/compliance-dictionary

[2] ComplianceOnline. (n.d.). Affiliated Covered Entity. ComplianceOnline. Retrieved from https://www.complianceonline.com/dictionary/healthcare-compliance-terminology/affiliated-covered-entity.html

[3] CMS.gov. (n.d.). Glossary. Centers for Medicare & Medicaid Services. Retrieved from https://www.cms.gov/glossary

[4] Compliancy Group. (n.d.). HIPAA Glossary: Important Definitions of HIPAA Terms. Compliancy Group. Retrieved from https://compliancy-group.com/hipaa-glossary-important-definitions-of-hipaa-terms/