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


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)