INDUSTRY ORGANIZATIONS & ROLES Flashcards
Accrediting Bodies
Independent organizations that assess and verify the quality of healthcare organizations, ensuring they meet predefined standards. Think of them as “quality watchdogs” for healthcare.
The Joint Commission (TJC)
Primary hospital accrediting body that:
-Sets standards for credentialing and privileging
-Requires verification of practitioner qualifications
Focuses on patient safety and quality of care
-Grants “deemed status” for Medicare participation
Key phrase: “Hospital-focused quality standards”
NCQA (National Committee for Quality Assurance)
Primary managed care accrediting organization that:
-Accredits health plans and managed care organizations
-Sets standards for credentialing practitioners in health plans
-Focuses on standardized quality measures (HEDIS)
-Emphasizes ongoing monitoring requirements
Key phrase: “Health plan quality standards”
HEDIS (Healthcare Effectiveness Data and Information Set)
A set of standardized performance measures used to assess the quality of healthcare plans. It’s like a report card for health plans.
Developed by:
NCQA (National Committee for Quality Assurance)
Purpose: To measure performance in areas like preventive care, chronic disease management, and member satisfaction.
Used by: Most health plans in the U.S. to compare their performance and identify areas for improvement.
URAC (Utilization Review Accreditation Commission)
Health plan accrediting body that:
-Accredits healthcare management organizations
Sets standards for network providers
-Focuses on utilization management
-Emphasizes consumer protection
Key phrase: “Healthcare management standards”
DNV (Det Norske Veritas)
Hospital accrediting organization that:
-Provides alternative to TJC accreditation
-Integrates ISO 9001 quality management
(ISO 9001 is a globally recognized standard that outlines the requirements for a quality management system)
-Grants deemed status for Medicare participation
-Emphasizes continuous improvement
Key phrase: “Quality management integration”
CMS (Centers for Medicare & Medicaid Services)
Federal agency that:
-Establishes Conditions of Participation (CoPs)
-Sets Medicare/Medicaid requirements
-Grants deemed status authority
-Oversees healthcare facility compliance
Key phrase: “Federal healthcare regulator”
OIG (Office of Inspector General)
Federal agency that:
-Maintains exclusion (database
-Investigates healthcare fraud
-Enforces compliance with federal programs
-Issues sanctions and penalties
Exclusion: means that a healthcare provider or entity is prohibited from participating in any federal healthcare programs.
Sanction: penalty imposed by the Office of Inspector General (OIG) on healthcare providers, entities, or individuals who have engaged in fraud or abuse related to federal healthcare programs.
Key phrase: “Fraud and abuse enforcer”
ACHC (Accreditation Commission for Health Care)
Previously known as HFAP (Healthcare Facilities Accreditation Program)
Healthcare facility accrediting organization that:
-Originated as AOA’s accrediting arm
-Provides deemed status for Medicare participation
Sets standards for:
-Hospital credentialing
-Non-physician practitioners
-Professional references (1 required, 3 preferred)
-Criminal background checks (7-10 year history)
-OPPE/FPPE requirements
Key phrase: “Hospital accreditation alternative”
Unique features: Direct quote of CMS regulations; requires collaborative/supervisory agreements for NPs/PAs
AAAHC (Accreditation Association for Ambulatory Health Care)
Ambulatory care accrediting organization that:
-Primary accreditor for ambulatory surgery centers
-Focuses on outpatient facilities including:
Surgery centers
Office-based surgery
Primary care offices
Dental offices
-Sets standards for:
Physician and dentist credentialing (minimum requirement)
Primary or secondary source verification
Board determines AHP privileges
Three-phase privileging process
Key phrase: “Outpatient facility expert”
Unique features: Uses term “secondary source verification”; requires ongoing monitoring of board certification
ABMS (American Board of Medical Specialties)
Organization that:
-Oversees 24 medical specialty boards
-Establishes standards for physician certification
-Verifies board certification status
-Maintains database of board-certified physicians
Key phrase: “Board certification authority”
AMA (American Medical Association)
Organization maintaining:
-Physician Masterfile (designated equivalent source)
-Education and training verification
-Board certification verification
-DEA registration verification (for MDs)
Key phrase: “Physician information authority”
AOA (American Osteopathic Association)
Organization that:
-Maintains osteopathic physician profiles
-Verifies DO education and training
-Provides board certification verification
-Serves as designated equivalent source
Key phrase: “Osteopathic authority”
NPDB (National Practitioner Data Bank)
Federal repository that:
-Collects adverse actions
-Records malpractice payments
-Maintains disciplinary actions
-Requires mandatory reporting
Key phrase: “Adverse action repository”
FCVS (Federation Credentials Verification Service)
*a part of FSMB
Service that:
-Provides centralized verification repository
-Maintains permanent credentials profiles
-Performs primary source verification
-Serves state medical boards
Key phrase: “Permanent credentials repository”
