Learning
Credentialing
Compliance
Accountable Care Organizations (ACO)
Groups of doctors, hospitals, and other healthcare providers who provide coordinated, high-quality, and affordable care to Medicare patients.
Accounting and Auditing Enforcement Releases (AAER)
Documentation that lists individuals or entities, identified by the U.S. Securities and Exchange Commission (SEC), who allegedly engaged in accounting misconduct, auditing misconduct, or both.
Accreditation
A method by which organizations such as hospitals, practices, and other healthcare-related institutions establish their ability to meet the requirements and standards of regulatory agencies that govern various aspects of the healthcare industry.
Advanced Cardiovascular Life Support (ACLS)
A certification specifically designed for medical professionals proficient in CPR and BLS; ACLS builds on the foundation of Basic Life Support (BLS) and is intended for healthcare personnel whose role is to perform or direct life-saving techniques in the event of cardiopulmonary arrest or other cardiovascular emergencies.
Affiliated Covered Entity (ACE)
Separate healthcare entities affiliated through shared ownership who designate themselves as a single covered entity in order to reduce the burden of HIPAA administration, requiring only one notice of privacy rights, one set of policies and procedures, one privacy official, one common training program, etc.
Agency for Healthcare Research and Quality (AHRQ)
Operates within the U.S. Department of Health and Human Services (HHS) to ensure evidence-based data is produced and understood; mission is to make healthcare safer, higher quality, more accessible, equitable, and affordable; invests in health system research, creates tools and strategies for practice improvement, and disseminates data and analytics.
Ambulatory Surgery Center (ASC)
A healthcare facility that specializes in providing surgical services in an outpatient setting, allowing patients to return home the same day of their procedure.
American Recovery and Reinvestment Act of 2009 (ARRA)
Stimulus package signed into law on February 17th, 2009 to modernize the United States infrastructure, enhance energy independence, expand educational opportunities, preserve and improve affordable health care, provide tax relief, and protect those in greatest need.
Americans with Disabilities Act (ADA)
A civil rights law that protects people with disabilities from discrimination.
Annual Contractor Evaluation Report (ACER)
A documented analysis of the relationship between contracted parties (such as a healthcare facility and Medicare/Medicaid) that measures standards of performance, adherence to certain tasks and schedules, ethics and integrity, workmanship, behavior among patient relationships, controlling of costs, etc.
Automated External Defibrillator (AED)
A portable medical device that diagnoses life-threatening cardiac emergencies with the ability to treat them through an application of electricity called defibrillation in order to re-establish an effective rhythm.
Basic Life Support (BLS)
Certification designed for healthcare workers and first responders that consists of a comprehensive group of life-saving medical techniques, including CPR with additional interventions for cardiac arrest, respiratory distress, and obstructed airways; employees in healthcare settings are generally required to obtain BLS certification in conjunction with Cardiopulmonary Resuscitation (CPR), which require regular training refreshers.
Cardiopulmonary Resuscitation (CPR)
A series of medical interventions performed on patients in cardiac arrest; intended to provide emergency oxygenation and circulation to the body; the American Heart Association (AHA) provides the most commonly used guidelines; employees in healthcare settings are generally required to obtain CPR certification in conjunction with Basic Life Support (BLS), which require regular training refreshers.
CARF Accreditation
CARF accreditation refers to the certification granted by the Commission on Accreditation of Rehabilitation Facilities (CARF), an international, independent, nonprofit accreditor that ensures high standards of quality and service in health and human services organizations.
Centers for Disease Control and Prevention (CDC)
As a branch of the U.S. Department of Health and Human Services (HHS), the CDC works to increase the health security of the United States by conducting critical science and disseminating health information that protects Americans from expensive and dangerous health-related threats, and responds accordingly when these arise.
Centers for Medicare & Medicaid Services (CMS)
Part of the U.S. Department of Health and Human Services (HHS) that provides health coverage at a lower cost to millions of people through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and the Health Insurance Marketplace.
Certified Compliance and Ethics Professional (CCEP)
A credentialed individual whose role is to help healthcare organizations understand their responsibilities in relation to the law and help healthcare organizations ensure compliance in their programs and services.
Certified Compliance and Ethics Professional-Fellow (CCEP-F)
A credentialed individual with knowledge and expertise in regulatory compliance processes who assists organizations in understanding and addressing legal obligations, and promotes integrity via effective compliance programs.
Certified Compliance and Ethics Professional-International (CCEP-I)
A credentialed individual with knowledge and international expertise in regulatory compliance processes who assists organizations in understanding and addressing legal obligations, and promotes integrity via effective compliance programs.
Certified Fraud Examiner (CFE)
A credentialed individual with special training in preventing, detecting, and investigating fraud; can work in a variety of positions and industries.
Certified Internal Auditor (CIA)
A credentialed individual who strives to increase defenses and minimize risk by ensuring compliance, performing audits on financial data, and protecting assets through the creation of systems that prevent fraud, loss, and theft.
Chief Audit Executive (CAE)
A professional who oversees and manages internal audit activity in accordance with the International Professional Practices Framework.
Chief Compliance Officer (CCO)
A professional leader who oversees organizational compliance by ensuring compliance with laws, regulatory requirements, policies, and procedures.
Chief Risk Officer (CRO)
A professional leader who identifies, examines, and minimizes external, internal, technical, regulatory, or competitive risks to a company; maintains compliance and protects investments.
Children’s Health Insurance Program (CHIP)
A United States federal healthcare program that provides low-cost health coverage to children in families who earn too much to qualify for Medicaid but cannot afford private insurance.
Civil Monetary Penalty (CMP)
A fine issued by the U.S. Department of Health and Human Services (HHS) for committing fraud and abuse involving Medicare or Medicaid, in violation of Civil Monetary Penalties Law (CMPL).
Clinical Laboratory Improvement Amendments (CLIA)
This 1988 amendment (42 USC 263a) and the associated regulations (42 CFR 493) provide the authority for certification and oversight of clinical laboratories and laboratory testing; there are different types of CLIA certificates issued by CMS, as well as different regulatory requirements, based on the types and complexity of clinical laboratory tests a laboratory conducts.
Community Health Center (CHC)
A non-profit, community-driven healthcare facility that provides primary care, dental, mental health, and other services to underserved populations, regardless of the patient’s insurance coverage or ability to pay for services.
Compliance Audit
A compliance audit is a series of inspections and checks performed by objective individuals or governing bodies to ensure that the healthcare entity is conducting business in accordance with its policies and federal or state regulations.
Compliance Certification Board (CCB)
A credentialing agency that certifies individuals who demonstrate competence in compliance and ethics.
Compliance Checklist
A compliance checklist is a comprehensive list used to aid in the completion of a procedure or task, identify areas for improvement, and improve the safety and security of patients and healthcare workers.
Compliance Officer
A professional that ensures a company, organization, and its employees adhere and comply with outside contractual obligations, government regulations and laws, as well as internal obligations and bylaws.
Consolidated Omnibus Budget Reconciliation Act (COBRA)
A federal law that mandates employers provide employees and their families the option to retain group plan health benefits for a certain period of time given particular circumstances such as involuntary or voluntary unemployment, employee death, decreased work hours, or other important life events.
Continuing Education (CE)
A broad term for any continuing education that’s done in pursuit of skill development in a person’s respective field. The requirements for CE vary depending on the profession and may be mandated by licensing boards or professional organizations. CEs must be provided by an accredited organization, such as American Nurses Credentialing Center (ANCC).
Continuing Education Units (CEUs)
A standardized way of quantifying continuing education (CE). Typically, one CEU is equal to 10 contact hours of participation in an organized CE activity. CEUs are required for many roles in the healthcare field, including nurses, pharmacists, counselors, and more.
Continuing Medical Education (CME)
Courses with credits delivered by accredited CME providers and designed specifically for physicians and other medical professionals. Many states require a specific number of CMEs for each license renewal cycle.
Credentialing
A systematic process used by healthcare organizations to verify and evaluate the qualifications, competence, and professional background of healthcare providers.
Credentialing Specialist
A “behind the scenes” worker in the healthcare industry whose primary role is to review and verify the educational background, licenses, certifications, and work experience of a caregiver, and to ensure healthcare professionals maintain their credentials by monitoring exclusion checks and expiration dates of licenses and certifications.
Cybersecurity
Cybersecurity is crucial in healthcare as it protects sensitive patient data from breaches and cyber-attacks, ensuring patient privacy, maintaining trust in healthcare systems, and complying with legal standards like HIPAA.
Designated Health Services (DHS) (Stark Law)
Specific services considered unlawful in relation to the Stark Law, which forbids physicians from referring patients to receive particular services from entities with which the physician or physician’s family member has a financial relationship.
Disaster Recovery Plan (DRP)
A detailed procedural document used to mitigate the impact of unplanned catastrophes that affect patient data and care.
Electronic Health Record (EHR)
An electronic version of a patient’s overall medical history, treatments, and clinical data extending beyond a given office location; shared amongst all providers involved in a patient’s care.
Electronic Medical Record (EMR)
An electronic version of a patient’s chart that is not shared outside a given office location; used to document diagnoses and treatments provided within a specific office location.
Electronic Protected Health Information (ePHI)
Electronic Protected Health Information (ePHI) is personal health-related information federally protected by the HIPAA Privacy Rule, that is electronically created, stored, transmitted, or received.
Enrollment
The process by which a healthcare provider is approved to participate in a health insurance network; payer enrollment is always completed after a provider completes a process known as credentialing to verify their qualifications.
Enterprise Risk Management (ERM)
A top-down process by which an organization, company, business, or firm identifies, analyzes, and prepares for risks that may harm finances, goals, or operations.
Equal Employment Opportunity Commission (EEOC)
An entity of the United States Government responsible for enforcing federal laws that make it illegal to discriminate against a job applicant or an employee because of the person’s race, color, religion, sex (including pregnancy and related conditions, gender identity, and sexual orientation), national origin, age (40 or older), disability or genetic information.
Ergonomics
Ergonomics is the scientific discipline concerned with designing and arranging workplaces, products, and systems to fit the people who use them, aiming to enhance efficiency, safety, and comfort.
Exclusion Check
The process of verifying that a healthcare provider is not barred from participating in federal healthcare programs, typically by checking databases such as the Office of Inspector General’s List of Excluded Individuals/Entities (OIG-LEIE) and System for Award Management (SAM).
Exclusions Monitoring
The ongoing process of ensuring healthcare providers and staff are not listed on federal or state exclusion lists, such as the OIG-LEIE or SAM databases, which would prohibit providers from participating in federally-funded healthcare programs.
Family Medical Leave Act (FMLA)
A federal law that allows eligible employees to take unpaid, job-protected leave for up to 12-weeks per year for family and medical reasons; group health benefits are maintained during the leave.
Federally Qualified Health Center (FQHC)
A healthcare facility that qualifies for special funding and enhanced reimbursement from the Health Resources and Services Administration (HRSA) and Centers for Medicare and Medicaid Services (CMS) having met certain criteria; for example: serve an underserved population, provide comprehensive care, maintain a quality assurance program, and other qualifiers.
Financial Assistance Policy (FAP)
A written document established by tax-exempt hospitals that guarantees eligible patients who cannot pay for treatment receive free or discounted services; regulated by the Internal Revenue Service (IRS).
Globally Harmonized System of Classification and Labeling of Chemicals (GHS)
Adopted by the United Nations (UN) in 2003 and aligned with OSHA’s Hazard Communication standard (HCS), the GHS specifies criteria for the classification of health, physical, and environmental hazards, and specifies information that should be included on labels and safety data sheets for hazardous chemicals.
Hazard Communication Standard (HCS)
An enforcement by the Occupational Safety and Health Administration (OSHA) that requires labels and information about the hazards of chemicals be available and understandable to a facility’s workers. The standard also requires accessible safety data sheets and proper training for staff.
Health Care Fraud Prevention and Enforcement Action Team (HEAT)
An organization created by the U.S. Department of Health and Human Services (HHS), Office of Inspector General (OIG), and the U.S. Department of Justice (DOJ) to address healthcare fraud and its prevention.
Health Information Management (HIM)
The collection, evaluation, saving, and protection of patient health information, whether that information is maintained in an electronic health record or on paper.
Health Information Technology for Economic and Clinical Health Act (HITECH)
Signed into law on February 17, 2009 (as part of the American Recovery and Reinvestment Act of 2009 (ARRA)) to promote the adoption and meaningful use of health information technology; addresses privacy and security concerns associated with the electronic transmission of protected health information by strengthening the enforcement of the HIPAA Privacy and Security Rules.
Health Information Trust Alliance (HITRUST)
A non-profit company that assists healthcare organizations with maintaining compliance, processing data, and managing information risk.
Health Insurance Marketplace
An online service available in the United States, established under the Affordable Care Act, where individuals, families, and small businesses can compare and purchase health insurance plans, often with eligibility for federal subsidies based on income.
Health Insurance Portability and Accountability Act (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law intended to protect patient rights and privacy by prohibiting healthcare organizations and insurance companies from disclosing sensitive and protected health information (PHI) without the patient’s consent.
Health Maintenance Organization (HMO)
A health insurance plan that consists of a network of physicians, hospitals, and healthcare providers that provides insurance coverage to individuals for either a monthly or an annual fee.
Health Resources and Services Administration (HRSA)
A sub-agency of the U.S. Department of Health and Human Services (HHS) focused on equitable healthcare for people who are geographically isolated and economically or medically vulnerable.
Healthcare Compliance
Healthcare Compliance is the process by which healthcare organizations and professionals follow a set of rules and regulations established by the practice itself, local, state, or federal bodies that promote and govern the quality of healthcare provided and the safety of patients, workers, and the general public.
Healthcare Regulation
Pertains to laws created and enforced by private organizations and all levels of government, including local, state, or federal. Healthcare regulations are designed to ensure that safe, quality healthcare is provided to the public by maximizing the compliance of healthcare personnel and providers. Ultimately, healthcare regulation protects the public, healthcare personnel, and healthcare providers.
HIPAA Privacy Rule
Enforced by the Office for Civil Rights, this federal law establishes standards for the protection of individuals’ protected health information (PHI); the rule governs how healthcare providers, health plans, and healthcare clearinghouses handle and safeguard PHI.
HIPAA Security Rule
Enforced by the Office for Civil Rights, this federal law sets standards for securing electronic PHI (ePHI); it mandates the implementation of administrative, technical, and physical safeguards to protect ePHI.
Immediate Corrective Action Required (ICAR)
A citation administered by the Centers for Medicare and Medicaid Services (CMS) as a result of uncovering a deficiency during an audit that resulted in lack of access to medications and/or services or posed an immediate threat to enrollee health and safety.
In-Network
Refers to a healthcare provider being credentialed and contracted with an insurance company, or payer, to provide services to covered individuals at negotiated rates.
Incident Report
A form that documents the details of an event such as workplace injury, accident, near miss, property damage, safety issues, health issues, or security breaches.
Infection Control Plan (ICP)
A healthcare Infection Control Plan (ICP) is a comprehensive strategy implemented by healthcare facilities to prevent and control the spread of infections within the facility, ensuring the safety of both patients and healthcare professionals.
Learning Management System (LMS)
A software application that facilitates professional education and training by organizing courses, providing access to the courses, monitoring the training progress of employees, and maintaining a record of each course completion.
Managed Care Organization (MCO)
A company, or healthcare plan, that strives to make services accessible and affordable; MCOs include Health Maintenance Organizations (HMOs), Point of Service (POS) Organizations, Preferred Provider Organizations (PPOs), and Exclusive Provider Organizations (EPOs).
Medicaid
A joint federal and state program in the United States that provides health coverage to eligible low-income adults, children, pregnant women, elderly adults, and people with disabilities, based on income and other criteria.
Medicare
A federal health insurance program in the United States primarily for individuals aged 65 and older, as well as for younger people with certain disabilities and individuals with End-Stage Renal Disease.
Merit-based Incentive Payment System (MIPS)
A program under the Centers for Medicare & Medicaid Services that adjusts Medicare payment rates to healthcare providers based on their performance in various categories, including quality, improvement activities, promoting interoperability, and cost.
National Labor Relations Act (NLRA)
Legislation intended to protect employer and employee rights, protect workers, businesses, and the economy by preventing harmful practices and encouraging collective bargaining.
Never Events
Never events in healthcare are serious, largely preventable patient safety incidents, such as wrong-site surgery or retained surgical items, that should not occur if proper safety protocols are followed.
Occupational Safety and Health Administration (OSHA)
Part of the United States Department of Labor and inspired from the Occupational Safety and Health Act of 1970, OSHA’s mission is to ensure safe conditions for employees at all workplaces through regulatory oversight and by providing training, outreach, education, and assistance.
Office for Civil Rights (OCR)
Part of the Department of Health and Human Services (HHS) that inspects and enforces federal civil rights laws, HIPAA, patient privacy and security, and policies and procedures for protected health information (PHI).
Office of Inspector General (OIG)
As a branch of the U.S. Department of Health and Human Services, the OIG focuses its resources on oversight of Medicare and Medicaid — programs that represent a large portion of the federal budget; a priority of the OIG is to safeguard funding and protect the country’s most vulnerable citizens by conducting audits to mitigate waste, fraud, and abuse.
Organized Health Care Arrangements (OHCA)
Organized healthcare systems in which multiple HIPAA-covered entities publicly acknowledge their participation in a joint arrangement with joint activities outlined by the Privacy Rule.
Out-of-Network
Refers to a healthcare provider who is not contracted with a patient’s insurance plan, often leading to higher out-of-pocket costs for patients seeking care from that provider.
Payer
Essentially another word for insurance company; examples of payers in the healthcare industry include organizations such as health plans, Medicare, and Medicaid; a payer sets service rates, collects payments, processes claims, and pays provider claims.
Pediatric Advanced Life Support (PALS)
Approved by the American Heart Association, a PALS certification includes Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) training specific to children and infants.
Physician Quality Reporting System (PQRS)
A “pay for performance” program that ran from 2007-2016 whereby eligible healthcare professionals reported to the Centers for Medicare and Medicaid Services (CMS) on quality measures; in 2017 PQRS was replaced by the Merit-based Incentive Payment System (MIPS).
Physician Query
A physician query is a formal communication tool used in healthcare settings, typically by medical coders or clinical documentation specialists, to request clarification or additional information from physicians regarding patient diagnoses, treatments, or procedures for accurate record-keeping and billing.
Primary Source Verification (PSV)
Primary Source Verification is the process of directly validating a healthcare provider’s credentials with the original issuing source to ensure authenticity and compliance with accreditation standards.
Privileging
The process of authorizing a healthcare professional to perform specific procedures and services within a healthcare facility, ensuring they meet stringent criteria for education, training, and experience.
Protected Health Information (PHI)
Protected Health Information (PHI) is personal health-related information federally protected by the HIPAA Privacy Rule.
Recredentialing
An ongoing process by which a provider’s initial credentials are reverified, typically every two to three years depending on each payer’s (insurance company’s) requirements.
Risk Assessment
In healthcare, a risk assessment is the systematic process of identifying, evaluating, and managing potential risks to patient safety, staff well-being, and organizational integrity, often to prevent harm and ensure quality care.
Securities and Exchange Commission (SEC)
According to the official website, “the SEC protects investors in the $3.8 trillion municipal securities markets that cities and towns rely on to provide neighborhood schools, local libraries and hospitals, public parks, safe drinking water and so much more.”
U.S. Department of Health and Human Services (HHS)
A branch of the U.S government whose mission is to promote the health and well-being of all Americans through oversight and by supporting proven, sustained advances in the sciences underlying medicine, public health, and social services; the HHS contains 12 separate divisions, including the Centers for Disease Control and Prevention (CDC), Centers for Medicare & Medicaid Services (CMS), Health Resources and Services Administration (HRSA), and others.