CHC (CCB) key terms

A formal set of policies, procedures, and oversight activities an organization uses to prevent, detect, and correct violations of law, regulation, and internal standards. It typically includes written standards, a compliance officer, training, monitoring, and enforcement.

The widely used framework describing the core components of a compliance program: written policies and procedures, designated compliance leadership, effective training and education, open communication lines, internal monitoring and auditing, consistent enforcement and discipline, and prompt response and corrective action.

The individual charged with day-to-day operation of the compliance program, including developing standards, coordinating training, leading audits, and reporting to senior leadership and the governing body on compliance risks and activities.

A cross-functional group of leaders from departments such as clinical, legal, finance, and operations that meets regularly to advise the compliance officer, review risk areas, and help prioritize compliance initiatives across the organization.

A written statement of the ethical and legal standards the organization expects of employees, contractors, and others acting on its behalf, often covering conflicts of interest, gifts, confidentiality, and reporting obligations.

The specific behavioral rules that translate the organization's values and legal obligations into everyday expectations for staff, such as prohibitions on falsifying records or accepting improper gifts.

Written documents that state what the organization requires (policies) and how it must be carried out (procedures), providing the operational detail staff need to comply with laws, regulations, and internal expectations.

The process of managing versions, approvals, effective dates, and periodic review of policies and other controlled documents so that only current, authorized versions are available to staff.

A program that is adequately resourced, well designed, and actually applied in practice, such that it can reasonably be expected to prevent and detect misconduct; regulators assess effectiveness rather than mere existence of written standards.

A structured process for identifying, analyzing, and prioritizing compliance risks based on likelihood and potential impact, so that resources and monitoring can be directed to the highest-risk areas.

A living inventory that records identified compliance risks, their likelihood and impact ratings, assigned owners, and mitigation plans, allowing leadership to track and update the organization's risk profile over time.

The amount and type of risk an organization is willing to accept in pursuit of its objectives, which guides decisions about where to invest controls and when a risk requires immediate action.

A documented set of actions, owners, and deadlines designed to reduce an identified risk to an acceptable level, including new controls, training, or monitoring activities.

An independent, objective review function that evaluates the design and operating effectiveness of controls and reports findings to leadership and the governing body, separate from the compliance function it may review.

A focused review that tests whether staff and processes are following applicable laws, regulations, and internal policies, often using sampling and documentation review to identify gaps and areas for correction.

The process of examining evidence to determine whether a control is designed appropriately and operates as intended over a period, often through walkthroughs, inquiry, observation, and re-performance.

Selecting a subset of records or transactions from a larger population for review, using a documented and defensible method, to draw conclusions about whether the full population complies.

An initial review of a process or area that establishes current performance and identifies existing gaps, providing a starting point against which later monitoring and improvement can be measured.

A comparison of current practices against a required standard, such as a regulation or policy, to identify where the organization falls short and what changes are needed.

A written plan that specifies the steps, responsible persons, and completion dates for fixing a deficiency identified through audit, investigation, or monitoring, and for verifying the fix worked.

Ongoing, routine oversight activities such as reviews, reports, and spot checks that detect problems early, distinct from periodic audits that examine a defined period in depth.

A measurable value used to track how well a process or control is performing, such as the percentage of claims reviewed or the rate of training completion, supporting data-driven monitoring.

The use of software and statistical techniques to examine large data sets, such as claims or billing records, to detect unusual patterns that may indicate errors, fraud, or control weaknesses.

A category of conduct and inefficiency that harms health care programs: fraud is intentional deception for gain, waste is misuse of resources without intent, and abuse is practices inconsistent with sound business or clinical standards.

A federal statute that imposes liability on persons who knowingly submit, or cause to be submitted, false or fraudulent claims for payment to government programs, and that allows whistleblowers to sue on the government's behalf.

A lawsuit brought by a private person, called a relator, on behalf of the government under the False Claims Act; the relator may share in any recovery, and the government may intervene in the case.

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

A federal physician self-referral law that prohibits physicians from referring patients for certain designated health services to entities with which the physician or an immediate family member has a financial relationship, unless an exception applies.

A regulatory provision that describes a payment or arrangement which, if fully met, is protected from prosecution under the Anti-Kickback Statute; compliance with a safe harbor is voluntary but provides certainty.

A sanction that bars a person or entity from participating in federal health care programs; billing for services furnished by an excluded individual can create liability, so screening is a core compliance control.

The process of checking employees, contractors, and vendors against government lists of excluded or debarred parties before hiring or contracting and periodically thereafter to prevent improper billing.

A federal law that, among other things, sets national standards for protecting the privacy and security of individually identifiable health information and establishes penalties for impermissible uses and disclosures.

Individually identifiable health information held or transmitted by a covered entity or business associate, in any form, that is protected by privacy and security rules governing its use and disclosure.

The requirement that, when using or disclosing protected health information, an organization limit the information to the least amount reasonably needed to accomplish the intended purpose.

A person or entity that performs functions or services for a covered entity involving access to protected health information, and that must agree in writing to safeguard that information.

A preventive control in which the organization verifies that employees, contractors, and vendors are not excluded from federal health care programs, typically at hire and on a recurring schedule.

A situation in which a person's private interests, such as outside financial relationships, could improperly influence their professional judgment or decisions made on behalf of the organization.

Rules that set limits on accepting or giving items of value to or from vendors, referral sources, and others, designed to avoid improper influence and anti-kickback concerns.

Legal and organizational safeguards that prohibit retaliation against individuals who report suspected wrongdoing in good faith, encouraging early disclosure of compliance problems.

A written commitment that staff who raise concerns or participate in investigations will not face retaliation, together with a process for investigating and correcting any retaliation that occurs.

A confidential channel, often anonymous, through which employees and others can report suspected compliance concerns, questions, or misconduct to the organization for review and follow-up.

A written commitment that staff who raise concerns or participate in investigations will not face retaliation, together with a process for investigating and correcting any retaliation that occurs.

A structured, documented inquiry into an allegation of misconduct that gathers evidence, interviews relevant parties, reaches findings, and determines appropriate corrective and disciplinary action.

The tracking of a compliance concern from intake through investigation, resolution, and follow-up, including documentation of findings, actions taken, and any reporting obligations.

Consequences applied when individuals violate policies or law, ranging from retraining and counseling to termination, intended to deter misconduct and demonstrate consistent enforcement.

A process for determining which staff need compliance education, on which topics, and at what depth, based on their roles, risk exposure, and prior audit or investigation findings.

Compliance education tailored to the specific duties and risk areas of a job function, such as billing staff receiving coding and documentation training, rather than a single generic course for everyone.

The measure of whether education actually changed knowledge and behavior, evaluated through methods such as post-tests, competency checks, and observed performance rather than attendance alone.

The practice of ensuring that diagnosis and procedure codes, charges, and claims accurately reflect the services documented in the medical record and meet payer and regulatory requirements.

The accuracy and completeness of the medical record in supporting the services billed, so that claims are supported by evidence of medical necessity, the service provided, and the provider's authentication.

A payment received that exceeds the amount properly payable, which generally must be identified, quantified, and returned within defined timeframes once identified.

A voluntary process in which an organization reports its own identified compliance violations to a government agency, often in exchange for more favorable resolution terms than if the issue were discovered externally.

The pre-contract and ongoing review of third parties for integrity, exclusion status, and compliance capability, since an organization can be held responsible for its contractors' conduct.

A chronological record of system activity, such as who accessed or changed a record and when, used to detect unauthorized activity and to support investigations and audits.

A structured method for determining the underlying reasons a problem occurred, rather than only describing the symptom, so that corrective actions address the true source of the deficiency.

The structures and processes by which the governing body and senior leaders oversee the compliance program, including accountability, reporting relationships, and resource decisions.

The visible commitment of senior leaders and the governing body to ethical conduct and compliance, which shapes whether staff take standards seriously and report concerns.