ABA HALM key terms

A federal criminal law that prohibits knowingly offering, paying, soliciting, or receiving anything of value to induce or reward referrals of items or services reimbursed by federal health care programs.

A federal civil statute barring physicians from referring patients for designated health services to entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

A federal statute imposing civil liability on persons who knowingly submit or cause the submission of false or fraudulent claims to government payers, including through treble damages and per-claim penalties.

A lawsuit brought by a private whistleblower on behalf of the government alleging fraud, in which the relator may receive a share of any recovery under the False Claims Act.

A regulatory provision that describes a payment or business arrangement which, if fully met, is deemed not to violate the Anti-Kickback Statute despite involving remuneration to referral sources.

A federal statute authorizing administrative fines and program exclusion for conduct such as presenting improper claims, paying prohibited inducements to beneficiaries, or violating assignment and billing rules.

A negotiated compliance document between an organization and the government, typically following a fraud settlement, requiring specified compliance program elements and monitoring over a set term.

A sanction imposed by the HHS Office of Inspector General that bars an individual or entity from receiving payment from Medicare, Medicaid, and other federal health care programs.

A defined list of services, including clinical laboratory, imaging, and inpatient hospital services, that are subject to the Stark Law's physician self-referral prohibitions when a financial relationship exists.

The price at which a willing buyer and willing seller, neither under compulsion and both having reasonable knowledge of the facts, would agree to exchange property or services.

A structured set of policies, oversight, training, monitoring, and enforcement activities an organization adopts to prevent, detect, and correct violations of law and internal standards.

The designated individual responsible for overseeing an organization's compliance program, including policy development, training, investigation of concerns, and reporting to leadership.

Legal and organizational safeguards that prohibit retaliation against employees who report suspected wrongdoing in good faith, encouraging internal and external reporting of compliance concerns.

A federal law that, among other goals, establishes national standards for protecting the privacy and security of individually identifiable health information held by covered entities and their business associates.

Individually identifiable health information transmitted or maintained in any form or medium that relates to a person's health, care, or payment for care.

A person or entity that performs functions or services involving protected health information on behalf of a covered entity, such as billing, claims processing, or legal services.

The principle that uses and disclosures of protected health information should be limited to the least amount reasonably needed to accomplish the intended purpose.

The requirement to notify affected individuals, regulators, and sometimes the public when unsecured protected health information is acquired or disclosed without authorization, within defined timeframes.

A federal law requiring hospitals with emergency departments to provide a medical screening examination and stabilizing treatment to anyone presenting with an emergency condition, regardless of ability to pay.

The improper refusal to treat or the inappropriate transfer of a patient with an emergency medical condition, which is prohibited under federal emergency treatment requirements.

Federal regulatory standards that a health care organization must meet to participate in Medicare and Medicaid, covering areas such as patient rights, quality, governance, and infection control.

A voluntary or deemed-status process in which an independent body evaluates an organization against recognized quality and safety standards, often satisfying Medicare conditions of participation.

The mandatory state-granted authorization that permits an individual or facility to practice a profession or operate a health care service within that jurisdiction.

The set of activities, procedures, and responsibilities that a licensed health professional is legally permitted to perform based on state law and professional standards.

The process of verifying a practitioner's education, licensure, training, and experience to determine eligibility to provide services and obtain privileges within an organization.

The formal authorization granted by a health care organization allowing a practitioner to perform specified procedures or provide defined services within that facility.

A protected process in which health professionals evaluate the quality and appropriateness of care delivered by colleagues, often supporting quality improvement and credentialing decisions.

A patient's voluntary agreement to a treatment or procedure after receiving and understanding information about its nature, risks, benefits, and alternatives.

A written statement, such as a living will or durable power of attorney for health care, expressing a person's treatment preferences in advance of incapacity.

Foundational values guiding health care decisions, commonly including autonomy, beneficence, nonmaleficence, and justice, used to resolve moral questions in practice.

A situation in which a person's financial, personal, or professional interests could improperly influence decisions made in their organizational or fiduciary role.

The legal obligation of board members and officers to act in the best interests of the organization with loyalty and due care, ahead of personal interests.

The governing body ultimately accountable for an organization's mission, strategy, financial oversight, and compliance, delegating operational authority to management.

The internal governing document that sets rules for an organization's structure, board composition, meetings, voting, and amendment procedures.

The systematic process of identifying, assessing, mitigating, and monitoring exposures that could harm patients, staff, finances, or organizational reputation.

A structured retrospective method for investigating an adverse event to identify underlying system failures and prevent recurrence, rather than assigning individual blame.

An ongoing, data-driven effort to measure performance and redesign processes so that care becomes safer, more effective, and more consistent with evidence-based standards.

The process by which staff document adverse events, near misses, and unsafe conditions so the organization can investigate and address underlying causes.

The end-to-end financial process covering patient registration, charge capture, coding, claim submission, payment posting, and collections for services delivered.

A reimbursement method that pays a predetermined fixed amount for a defined service or episode, shifting financial risk for cost overruns to the provider.

A payment model in which a provider receives a fixed amount per enrolled patient per period in exchange for delivering a defined set of services.

A method of adjusting payments to health plans or providers based on the predicted health care costs of their enrolled populations, often using diagnoses to reflect acuity.

The practice of ensuring diagnostic and procedure codes and submitted claims accurately reflect documented services and meet payer rules and legal requirements.

An entity that contracts with payers and providers to coordinate and finance care for enrolled members, often using networks, utilization controls, and fixed payments.

A set of review activities, such as prior authorization and concurrent review, used to assess whether care is medically necessary and appropriate under a payer's coverage rules.

A collaborative process that assesses, plans, and coordinates services to meet an individual's health needs and improve outcomes while managing resource use.

The process by which leadership defines long-term goals, assesses internal and external conditions, and allocates resources to achieve the organization's mission.

A performance measurement framework that tracks financial, customer, internal process, and learning perspectives to align activities with organizational strategy.