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Healthcare Compliance Basics

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COBRA

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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.

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Nurse Practice Acts (NPAs)

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State laws that define the responsibilities and authorities of nurses within each state.

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Compliance Program

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A formalized program that includes policies, procedures, and practices to prevent, detect, and correct violations of healthcare laws and regulations.

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Medicare Part D

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Prescription drug coverage that is offered to anyone with Medicare.

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Privacy Rule

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A HIPAA standard that requires the protection and confidential handling of protected health information.

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False Claims Act

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A law that allows individuals to sue on behalf of the government for false claims made to federal programs and protects whistleblowers.

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Stark Law

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Prohibits physician self-referral, especially when referring a patient for certain designated health services payable by Medicare or Medicaid.

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HITECH Act

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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.

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HIPAA

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Health Insurance Portability and Accountability Act: ensures the protection and confidential handling of protected health information.

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GDPR

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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.

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Medicaid Integrity Program

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A program established to prevent and reduce Medicaid fraud, waste, and abuse and ensure the integrity of the Medicaid program.

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Anti-Kickback Statute

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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.

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Civil Monetary Penalties Law (CMPL)

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Allows the imposition of monetary penalties for various healthcare fraud offenses and has provisions against employing excluded individuals.

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CLIA

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Clinical Laboratory Improvement Amendments: federal standards for U.S. facilities that test human specimens for health assessment or to diagnose, prevent, or treat disease.

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Breach Notification Rule

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Under HITECH, this rule requires covered entities to notify affected individuals, HHS, and in certain circumstances, the media of a breach of unsecured PHI.

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MACRA

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Medicare Access and CHIP Reauthorization Act: changes the way Medicare rewards clinicians for value over volume.

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EMTALA

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Emergency Medical Treatment and Active Labor Act: requires hospitals to provide emergency medical treatment regardless of citizenship, legal status, or ability to pay.

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FCA Investigation

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Involves looking into false claims act violations where individuals or companies defraud governmental programs.

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Patient Safety Rule

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Provides a framework by which hospitals and other healthcare providers may voluntarily report information to Patient Safety Organizations, without fear of legal repercussion.

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FDA Regulations

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Rules issued by the Food and Drug Administration that govern the development, testing, approval, and sale of drugs and medical devices.

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Affordable Care Act (ACA)

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A comprehensive healthcare reform law enacted in March 2010 (sometimes known as ACA, PPACA, or 'Obamacare').

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Security Rule

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A HIPAA standard that establishes a national set of security standards for protecting certain health information that is held or transferred in electronic form.

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Omnibus Rule

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A HIPAA update that addresses changes related to genetic information nondiscrimination, enforcement, and breach notification.

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Quality Improvement System for Managed Care (QISMC)

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A set of standards and guidelines for evaluating the performance of managed care plans.

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Accountable Care Organization (ACO)

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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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