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)
- Deemed Status
Transitions of Care (TOC)
- Transitions of Care Models
- Affordable Care Act (ACA)
- American Recovery & Reinvestment Act (ARRA)
- Seven Essential Elements
- Readmission Reduction
Credentialing and Privileging
- Core Competencies
- The Data Bank
- Medical Staff Credentialing / Recredentialing
- Institutional Bylaws and Governance
- Provider Profiling
- Economic Credentialing
Pay-for-Performance &
Value-Based Care
- Interoperability
- Leapfrog Group
- Provider Performance
- Value-Based Care
- Healthcare Consumer Assessment of Healthcare Providers and Systems (HCAHPS)
Insurance and Managed Care
- Accountable Care Organizations
- Health Maintenance Organizations (HMOs)
- Medicare, Medicaid, and Military/VA programs
- Preferred Provider Organizations (PPOs)
- Health Care Delivery and Information Systems
Workers' Compensation (WC)
- Compensability
- Independent Medical Exams (IME)
- Disability Protocols
- Regulations
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Professional Roles in HCQM
- 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
- Concepts and Applications
- Quality Improvement Organizations (QIOs)
- Peer Review
- Continuous Quality Improvement (CQI)
- Total Quality Management (TQM)
- Physician Quality Reporting System (PQRS)
Utilization Management
- Readmissions and Length of Stay
- Medicare Audits: RACs, MACs, UPICs, etc.
- Utilization and Peer Review
- Medical Necessity
Clinical Resource Management
- Reimbursement Models and Accountable Care
- Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
- Demand & Disease Management
- ICD-10
Case Management
- Case Management Components
- Legal & Ethical Principles
- Integrated Case Management
- Informed Consent
Risk Management / Patient Safety
- Stark Laws
- Anti-Kickback Statutes / Safe Harbor
- Patient Self Determination Act (PSDA)
- Informed Consent
- Patient Safety Initiatives and Organizations
- 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)
- Privacy and Data Disclosure
- Affordable Care Act (ACA)
- Health Care Quality Improvement Act (HCQIA)
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