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Healthcare Compliance Basics
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COBRA
Consolidated Omnibus Budget Reconciliation Act: gives workers and their families the right to choose to continue group health benefits provided by their group health plan for limited periods.
Nurse Practice Acts (NPAs)
State laws that define the responsibilities and authorities of nurses within each state.
Compliance Program
A formalized program that includes policies, procedures, and practices to prevent, detect, and correct violations of healthcare laws and regulations.
Medicare Part D
Prescription drug coverage that is offered to anyone with Medicare.
Privacy Rule
A HIPAA standard that requires the protection and confidential handling of protected health information.
False Claims Act
A law that allows individuals to sue on behalf of the government for false claims made to federal programs and protects whistleblowers.
Stark Law
Prohibits physician self-referral, especially when referring a patient for certain designated health services payable by Medicare or Medicaid.
HITECH Act
Health Information Technology for Economic and Clinical Health Act: encourages the adoption of electronic health records and supports the privacy and security of healthcare information.
HIPAA
Health Insurance Portability and Accountability Act: ensures the protection and confidential handling of protected health information.
GDPR
General Data Protection Regulation: a regulation in EU law on data protection and privacy that also addresses the transfer of personal data outside the EU and EEA.
Medicaid Integrity Program
A program established to prevent and reduce Medicaid fraud, waste, and abuse and ensure the integrity of the Medicaid program.
Anti-Kickback Statute
A federal law that prohibits the exchange or offer of anything of value in an effort to induce or reward the referral of federal healthcare program business.
Civil Monetary Penalties Law (CMPL)
Allows the imposition of monetary penalties for various healthcare fraud offenses and has provisions against employing excluded individuals.
CLIA
Clinical Laboratory Improvement Amendments: federal standards for U.S. facilities that test human specimens for health assessment or to diagnose, prevent, or treat disease.
Breach Notification Rule
Under HITECH, this rule requires covered entities to notify affected individuals, HHS, and in certain circumstances, the media of a breach of unsecured PHI.
MACRA
Medicare Access and CHIP Reauthorization Act: changes the way Medicare rewards clinicians for value over volume.
EMTALA
Emergency Medical Treatment and Active Labor Act: requires hospitals to provide emergency medical treatment regardless of citizenship, legal status, or ability to pay.
FCA Investigation
Involves looking into false claims act violations where individuals or companies defraud governmental programs.
Patient Safety Rule
Provides a framework by which hospitals and other healthcare providers may voluntarily report information to Patient Safety Organizations, without fear of legal repercussion.
FDA Regulations
Rules issued by the Food and Drug Administration that govern the development, testing, approval, and sale of drugs and medical devices.
Affordable Care Act (ACA)
A comprehensive healthcare reform law enacted in March 2010 (sometimes known as ACA, PPACA, or 'Obamacare').
Security Rule
A HIPAA standard that establishes a national set of security standards for protecting certain health information that is held or transferred in electronic form.
Omnibus Rule
A HIPAA update that addresses changes related to genetic information nondiscrimination, enforcement, and breach notification.
Quality Improvement System for Managed Care (QISMC)
A set of standards and guidelines for evaluating the performance of managed care plans.
Accountable Care Organization (ACO)
A group of doctors, hospitals, and other healthcare providers who come together voluntarily to give coordinated high-quality care to their Medicare patients.
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