CHC (AHE) key terms

A structured set of policies, people, and processes an organization uses to prevent, detect, and correct violations of law, regulation, and its own ethical standards.

The widely used framework describing written standards, leadership oversight, training and education, open communication, monitoring and auditing, enforcement and discipline, and prompt corrective action as program foundations.

A foundational document stating an organization's ethical commitments and expected behaviors, giving staff a single reference for how to act lawfully and report concerns.

Written rules translating laws, regulations, and organizational values into specific expectations employees must follow in daily work, such as billing accuracy and conflict-of-interest rules.

A governing statement of principle that sets the organization's position on a topic and directs how decisions should be made, usually approved at a senior level.

A step-by-step description of how a task must be performed to comply with a policy, giving staff operational instructions that can be followed and audited.

The individual responsible for leading the compliance program day to day, including policy development, training, monitoring, investigation oversight, and reporting to leadership and the board.

A cross-functional group of leaders that meets regularly to review compliance risks, coordinate corrective actions, allocate resources, and advise the compliance officer on program priorities.

The structural arrangement ensuring the compliance leader has direct access to the board or a board committee, reducing the risk that compliance concerns are suppressed by management.

The board's duty to receive compliance reports, approve the program's scope and resources, and hold management accountable for ethical and lawful performance.

The signals senior leaders send through their words, decisions, and resource choices about whether ethical conduct and compliance are genuinely valued.

The shared assumptions and behaviors that determine how employees actually handle ethical dilemmas, including whether they feel safe raising concerns.

An environment in which workers are encouraged and protected when they raise questions or report suspected wrongdoing through internal channels.

The legal and policy protection preventing employers from punishing workers who report concerns or participate in investigations in good faith.

Statutes and rules that shield individuals who report suspected fraud or misconduct from retaliation and, in some programs, allow them to share in recovered funds.

A confidential reporting channel, often anonymous and available continuously, through which staff and others can report suspected misconduct.

The process of receiving reports, logging them, and deciding how urgently and how deeply each allegation should be investigated.

A systematic process of identifying compliance risks, judging their likelihood and impact, and ranking them to set program priorities and allocate resources.

A living inventory that records identified compliance risks, their ratings, the controls in place, and the owners responsible for managing each one.

A safeguard built into a process, such as segregation of duties or a required approval, that prevents or detects errors and misconduct.

Ongoing, routine checks built into daily operations that verify compliance with policies and procedures and flag problems early.

A formal, independent, and systematic examination of records or processes, usually performed on a sampling basis, to test whether controls are working.

A scheduled document listing the audits, monitoring reviews, and training activities planned for a period, with owners, timing, and scope.

A structured, confidential inquiry into an allegation of wrongdoing that gathers facts, applies relevant rules, and recommends action.

A legal doctrine protecting confidential communications between a client and a lawyer, sometimes used to shield investigation findings from disclosure.

A doctrine shielding materials prepared in anticipation of litigation from discovery, often applied to investigation notes and analysis.

A documented set of steps, deadlines, and owners created to fix a root cause identified through an audit, investigation, or incident.

A method for tracing a problem back to its underlying systemic cause rather than stopping at the individual who made the error.

Consistent consequences applied to staff who violate policy, ranging from coaching to termination, that demonstrate the program is enforced fairly.

Planned instruction that gives staff the knowledge and skills to follow policies and recognize compliance issues in their specific roles.

Instruction tailored to the particular risks of a job function, such as billing, coding, sales, or clinical roles, rather than one generic course for everyone.

Evidence that training changed knowledge or behavior, measured through testing, observation, or performance data rather than attendance alone.

A periodic evaluation of whether the compliance program is achieving its goals, using metrics, audit results, culture surveys, and incident trends.

The practice of using audit findings, investigation outcomes, and feedback to refine policies, training, and controls over time.

A federal statute imposing liability on those who knowingly submit false or fraudulent claims for government payment, with whistleblower provisions and treble damages.

A lawsuit brought by a private person on behalf of the government alleging fraud, in which the relator may receive a share of any recovery.

A federal law making it a crime to knowingly offer or receive remuneration to induce referrals of items or services paid by federal health care programs.

A federal strict-liability statute barring physician referrals of certain designated health services to entities with which the physician or immediate family has a financial relationship, absent an exception.

A regulatory provision describing an arrangement that will not be treated as a violation of the Anti-Kickback Statute if all of its conditions are met.

Federal regulations governing how covered entities may use and disclose protected health information and setting patient rights over their records.

Individually identifiable health information held or transmitted by a covered entity or business associate in any form.

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