ABA HALM flashcards

32 cards. Read the term and the definition here. The deck at the top of this page is optional.

Conditions of Participation

Federal health and safety requirements in 42 CFR 482 that a provider must meet to participate in Medicare; survey findings can lead to termination of Medicare billing privileges.

Stark Law

Prohibits physician self-referral of designated health services payable by Medicare unless a specific exception applies; it is a strict-liability civil statute with refund and penalty exposure.

Anti-Kickback Statute

Criminal statute prohibiting knowingly offering or receiving remuneration to induce referrals of items or services payable by federal health care programs; intent must be shown.

EMTALA obligation

A Medicare-participating hospital with an emergency department must provide a medical screening examination and stabilizing treatment regardless of the patient's ability to pay.

HIPAA breach notification

Covered entities must notify affected individuals without unreasonable delay and no later than 60 days after discovery of a breach of unsecured protected health information.

Minimum necessary standard

Requires limiting uses, disclosures, and requests for PHI to the least amount needed for the purpose; treatment disclosures and disclosures to the individual are excepted.

Compliance program seven elements

Written policies, designated compliance officer and committee, effective training, open communication lines, internal monitoring and auditing, enforcement and discipline, and prompt corrective action.

Exclusion screening

Checking the OIG List of Excluded Individuals/Entities and SAM.gov before hiring and monthly thereafter; billing for services furnished by an excluded person is prohibited.

Days in accounts receivable

A revenue cycle metric calculated as total accounts receivable divided by total charges, multiplied by the number of days in the period.

PDSA cycle

Plan-Do-Study-Act is a rapid-cycle improvement method used to test small changes, study results, and then adopt, adapt, or abandon the change.

Root cause analysis

A structured retrospective method used after an adverse event to identify contributing system factors and develop corrective actions with owners and deadlines.

Net patient revenue

Gross charges less contractual allowances and discounts; the contractual allowance is the difference between billed charges and the payer's allowed amount.

Contribution margin

Revenue minus variable costs; fixed costs are excluded, so it measures the amount available to cover fixed costs and contribute to margin.

Capitation

A payment model that pays a fixed amount per member per period regardless of the volume of services used, shifting utilization risk to the provider.

Fair market value requirement

Under Stark exceptions, compensation must be set in advance at fair market value and must not vary with the volume or value of referrals.

Duty of loyalty

A board fiduciary duty requiring directors to put the organization's interests ahead of personal interests and to disclose and recuse from conflicted decisions.

Informed consent elements

Disclosure of the nature of the procedure, material risks and benefits, reasonable alternatives, and the patient's right to refuse or withdraw consent.

Four principles of bioethics

Autonomy (respect for patient choice), beneficence (act for benefit), nonmaleficence (avoid harm), and justice (fair distribution of benefits and burdens).

Just culture

A framework distinguishing human error (console), at-risk behavior (coach), and reckless behavior (discipline), supporting nonpunitive reporting of errors and near misses.

Claims-made coverage

Professional liability insurance that responds to claims reported during the policy period, regardless of when the incident occurred, often requiring tail coverage.

Donabedian model

A quality measurement framework categorizing measures as structure (resources), process (actions), or outcome (results), used to organize quality dashboards.

Credentialing versus privileging

Credentialing verifies licensure, training, and experience; privileging authorizes a practitioner to perform specific services at a specific facility.

Failure mode and effects analysis

A prospective method that identifies ways a process can fail and scores severity, occurrence, and detectability to prioritize risk reduction before harm occurs.

Sentinel event

An unexpected occurrence involving death or serious physical or psychological injury; organizations typically conduct a root cause analysis within a defined timeframe.

Business associate agreement

A contract required before a covered entity discloses PHI to a business associate, specifying permitted uses, safeguards, and breach reporting obligations.

Health Care Quality Improvement Act

Federal statute providing limited immunity from damages for peer review participants who act in good faith and follow required due process standards.

OIG Work Plan

An annually updated list of audit and enforcement priorities published by the Office of Inspector General, used to prioritize compliance risk assessment and auditing.

Monitoring versus auditing

Monitoring is ongoing, routine review built into operations; auditing is periodic, independent, and documented review of a defined sample against standards.

Days cash on hand

A liquidity metric calculated as unrestricted cash and equivalents divided by average daily operating expenses, indicating how long operations can be funded.

Budget variance decomposition

Analysis that separates actual-to-budget differences into volume, rate, and mix components to identify the drivers of financial performance.

Conflict of interest recusal

When a director or officer has a material interest, they disclose it, abstain from voting, and the recusal is documented in the board minutes.

Statistical process control

A method using control charts to distinguish common-cause variation inherent in a process from special-cause variation signaling a real change requiring investigation.