📚 10 Legal Terms Every Healthcare Provider Should Know

Healthcare law can feel like alphabet soup — HIPAA, CMS, OIG, PHI. But behind the acronyms are real risks and real opportunities that affect your day-to-day practice.

Here are 10 essential legal terms every provider should understand — especially if you run or manage a private practice.

1. HIPAA (Health Insurance Portability and Accountability Act)

• The federal law that governs patient privacy and data security. It includes rules on electronic records, breach notifications, and business associate agreements (BAAs).

• 🔒 Why it matters: A HIPAA breach can lead to hefty fines — even if it was accidental.

2. PHI (Protected Health Information)

• Any identifiable patient information — from names to lab results. HIPAA requires strict protection of PHI.

• 🛡️ Tip: Don’t email PHI unless you’re using secure, encrypted systems.

3. Stark Law

• A federal law that prohibits physicians from referring patients to entities where they have a financial interest, unless a specific exception applies.

• ⚠️ Common trap: Referring to your own diagnostic center or therapy group without following compliance rules.

4. Anti-Kickback Statute (AKS)

• Makes it illegal to exchange anything of value for patient referrals for services covered by federal healthcare programs (like Medicare or Medicaid).

• 💰 Yes, free lunches count — and so do excessive “consulting” fees.

5. Fee Splitting

• Some states prohibit providers from splitting fees with non-providers (or even other providers) unless it’s structured properly.

• 💸 Watch out for marketing arrangements or partnerships where revenue is shared.

6. Medical Necessity

• The standard insurers use to determine whether a service is reasonable, appropriate, and necessary.

• 📋 Why it matters: Many denials (and audits) hinge on whether the service was documented as medically necessary.

7. Timely Filing Limit

• The deadline by which claims must be submitted to be eligible for payment — varies by payor.

• 🕒 Miss it? Your claim may be denied, even if the care was perfect.

8. Recoupment

• When a payor demands repayment for claims it believes were paid in error, often after an audit.

• ⚠️ Know your contract — some allow recoupments up to 24 months later.

9. Business Associate Agreement (BAA)

• A HIPAA-required contract between a provider and any vendor who accesses PHI (e.g., billing companies, IT firms, EMR vendors).

• 📝 Don’t work with third parties who handle PHI without a signed BAA.

10. Scope of Practice

• The legal boundaries of what your license allows you to do — varies by state and license type.

• 👩‍⚕️ Letting an MA perform services beyond their scope can create serious liability.

🧠 Final Word

You don’t need to be a lawyer — but understanding these terms helps you avoid common (and expensive) pitfalls.

Need help translating legal language into clear practice policies? That’s what I do.

📧 eric@hurleylawgroup.com
🌐 hurleylawgroup.com
🗓️ Book a consult today!