HCQM Exam Topics

The examination contains factual material, application of concepts, and realistic vignettes. The examination is reviewed and updated annually by a committee of Health Care & Quality Management experts.

Key concepts covered in the examination include:

Accreditation Organizations

  • American Board of Quality Assurance and Utilization Review Physicians (ABQAURP)
  • National Committee for Quality Assurance (NCQA)
  • Healthcare Effectiveness Data and Information Set (HEDIS®)
  • The Joint Commission
  • ISO (International Organization for Standardization)
  • National Quality Forum (NQF)

Transitions of Care (TOC)

  • Transitions of Care Models
  • Patient Protection & Affordable Care Act (PPACA)
  • American Recovery & Reinvestment Act (ARRA)
  • Seven Essential Elements
  • Readmission Avoidance

Credentialing and Privileging

  • Core Competencies
  • The Data Bank
  • Medical Staff Credentialing / Recredentialing
  • Institutional Bylaws
  • Economic Credentialing


  • Meaningful Use
  • Leapfrog Group
  • Provider Performance
  • Value-Based Purchasing

Insurance and Managed Care

  • Accountable Care Organizations
  • Health Maintenance Organizations (HMOs)
  • Medicare
  • Medicaid
  • Preferred Provider Organizations (PPOs)

Workers' Compensation (WC)

  • Compensability
  • Independent Medical Exams (IME)
  • Disability Protocols
  • Regulations

Physician Advisor Medical Specialty

  • Defining the Physician Advisor's Role
  • Two-Midnight Rule
  • Management of Observation Services
  • Medicare Audits, Denials, and Appeals
  • Transition to ICD-10

Quality Improvement, Management and Assurance

  • Theoretical Concepts
  • Quality Improvement Organizations (QIOs)
  • Peer Review
  • Continuous Quality Improvement (CQI)
  • Total Quality Management (TQM)
  • Physician Quality Reporting System (PQRS)

Clinical Resource Management

  • Utilization Review
  • Medicare Audits
  • Demand & Disease Management

Case Management

  • Case Management Components
  • Legal & Ethical Principles
  • Informed Consent

Risk Management / Patient Safety

  • Stark Laws
  • Anti-Kickback Statutes / Safe Harbor
  • Patient Self Determination Act (PSDA)
  • Informed Consent
  • Patient Safety Initiatives
  • Computerized Physician Order Entry (CPOE)

Regulatory Environment

  • Health Insurance Portability and Accountability Act (HIPAA)
  • Centers for Medicare & Medicaid Services (CMS)
  • Employee Retirement Income Security Act (ERISA)
  • Consolidated Omnibus Budget Reconciliation Act (COBRA)
  • Affordable Care Act (ACA)
  • Health Care Quality Improvement Act (HCQIA)