Clarifying: Licensure, Certification, and Accreditation (Part I)
Clarifying: Licensure, Certification, and Accreditation (Part I)

Let’s be as clear as water. In Health Care the lingo is spread and repetitive, at times confusing, especially when managers decide to use abbreviations that differ from common market standards. For instance, does Transition of Care Management (E/M Code) should be abbreviated TOC or TCM?

Similar linguistic confusions apply to governmental and other permissions.  In order to practice medical care, health care organizations and professionals must pass through screening processes allowing them to obtain: Licensure, Certification (For Medicare), and Accreditation. I know, the terms could get confusing because they interconnect in basic idea of permitting to practice somehow; however, in applicable definition they are different. The difference relies on the standard, subject to receive the permit, requirement, purpose, and oversight agency.

Licensure is the State governmental approval for a facility or a professional to practice within the limits of their profession. The requirement may vary from state to state but the baseline is similar especially on the grounds of mandatory compliance, which are overseen by regulatory agencies. Facilities and professionals must abide to state legislation. Federal health facilities are exempted from state licensure.

Certification for Medicare means to be eligible for reimbursement by complying with the conditions of participation (COP). Even though, compliance with COP is regulated by the state, Title XVIII, the Medicare Act, simultaneously grants facilities and providers, through the accreditation process a deemed status which is their certification. Officially: “Certification is when the State Survey Agency officially recommends its findings regarding whether health care entities meet the Social Security Act’s provider or supplier definitions, and whether the entities comply with standards required by Federal Regulations” (CMS).

Accreditation is the process of recognition for a program of study stating that the educational institution voluntarily demonstrates the abidance to meet pre-established standards. The accreditation process is reviewed and overseen by “private nongovernmental organizations or agency”. Several institutions are involved depending on the educational program. In our HIM World, the most prominent is Commission on Accreditation for Health Informatics and Information Management Education (CAHIIM).

I’m sure you have heard crazy Lingos, let’s keep it clean and clear and bring them on! As we share them, the confusion will be gone… eventually, I hope. Although, I’m a hopeful person.



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