- Corporate practice of medicine (CPOM)
- The doctrine that a corporation or lay person may not employ a physician to practice medicine or interfere with clinical judgment. It is a state-law question, not a federal one, and it is the first constraint on any ownership, investment or growth structure in outpatient care.
- Texas CPOM doctrine
- Texas enforces CPOM strictly: with narrow statutory exceptions, only physicians may own a practice, and practices are organized as professional associations or professional LLCs. Non-physician capital reaches Texas practices through a management arrangement, not through ownership of the clinical entity.
- MSO (management services organization)
- A non-clinical company that provides billing, staffing, real estate, IT, marketing and administration to a practice under a management services agreement, taking a fee. The MSO is how investors, payers and platforms participate economically in a market where they may not own the practice.
- Friendly PC model
- The paired structure in which a physician nominally owns the professional corporation while an affiliated MSO controls administration through the management agreement and a succession or transfer arrangement over the shares. It is the standard private-equity and payer structure and the exact target of recent state legislation.
- Texas Medical Board advertising rules
- Board rules governing physician advertising: no false, misleading or deceptive statements, no unsubstantiated superiority claims, required identification of the licensed physician responsible, and specific constraints on testimonials, guarantees and comparative claims. Marketing copy is regulated speech here, and the board disciplines against these rules.
- Deceptive claims and 'specialist' / board-certification language
- Two linked prohibitions that catch most clinic marketing. A physician may not be described as a specialist or as board certified unless certified by a board the state recognizes, and the certifying board must generally be named. Separately, any statement likely to create an unjustified expectation about results - cure rates, guaranteed outcomes, 'best in Austin', pain-free promises, undisclosed-cost 'free' offers - is prohibited regardless of intent. If a claim cannot be substantiated on request, it cannot be published.
- Stark Law
- The federal physician self-referral law barring a physician from referring designated health services payable by Medicare to an entity with which the physician or an immediate family member has a financial relationship, unless an exception applies. Strict liability: intent is irrelevant, so structure is everything.
- Anti-Kickback Statute (AKS) and safe harbors
- A criminal statute prohibiting knowingly offering, paying, soliciting or receiving remuneration to induce referrals of federally reimbursable services - broad enough to reach co-marketing deals, rent, medical directorships and lead-purchase arrangements that look ordinary in other industries. Regulatory safe harbors (space and equipment rental, personal services, employment, value-based arrangements and others) immunize an arrangement only if every element is met; partial compliance provides no protection, because a safe harbor is a checklist, not a defense in spirit.
- Beneficiary inducement CMP
- A civil monetary penalty for offering remuneration to a Medicare or Medicaid beneficiary that is likely to influence their choice of provider. This is why gift cards, prize drawings, waived copays and 'free' gifts above nominal value are off-limits in clinic promotions.
- HIPAA marketing authorization
- Using protected health information to make a marketing communication generally requires the patient's written authorization, and the authorization must disclose any payment received from a third party. Treatment, care coordination and limited refill reminders are the narrow exceptions.
- HIPAA online tracking technology guidance
- HHS OCR guidance stating that analytics, advertising pixels and session-recording tools on regulated pages may transmit protected health information to vendors without a business associate agreement or authorization. A 2024 federal court decision narrowed its reach on unauthenticated public pages, but the portal and appointment-request surfaces remain live exposure.
- Business associate agreement (BAA)
- The contract required before a vendor may create, receive, maintain or transmit PHI for a covered entity. Most general-purpose ad, analytics and CRM platforms will not sign one, which is precisely why a standard martech stack cannot simply be dropped onto a clinic site.
- TCPA
- The Telephone Consumer Protection Act, governing automated calls and texts. Appointment reminders and healthcare messages have narrow exemptions, but recall campaigns, promotions and anything marketing-adjacent need prior express written consent and a working opt-out.
- Patient reviews and HIPAA
- A public reply to an online review that acknowledges the person was seen, names a condition, or disputes their account of a visit is a disclosure of PHI. The compliant response is a generic invitation to contact the practice offline — and enforcement actions have been brought over exactly this.
- CPT code
- Current Procedural Terminology — the AMA-maintained code set identifying every service billed. The code, not the visit, is what a payer adjudicates.
- E/M level
- Evaluation and Management level, the code tier for an office visit reflecting its complexity. Level selection drives the majority of primary-care revenue and is the most frequently audited coding decision.
- 2021 E/M documentation changes
- The overhaul that eliminated history and exam as level-determining elements for office visits, basing level on medical decision-making or total time on the date of service. It moved the compliance question from how much was typed to whether the complexity or time is genuinely supported.
- Modifier 25
- Appended to signal a significant, separately identifiable E/M service on the same day as a procedure. Heavily scrutinized: payers have imposed automatic reductions and prepayment review, and unsupported use is a standard audit finding.
- Incident-to billing
- Billing an NP or PA service under a supervising physician's NPI at full physician rate, permitted only when strict conditions on an established plan of care and direct supervision are met. High reimbursement upside and correspondingly high enforcement risk.
- Split/shared visit
- A visit performed jointly by a physician and an advanced practice provider in a facility setting, billed by whichever clinician furnished the substantive portion. CMS's definition of 'substantive' has shifted, so policy must be re-checked rather than assumed.
- RVU and wRVU
- Relative Value Unit — the work, practice-expense and malpractice weighting assigned to each service. Work RVUs are the standard unit of physician productivity and the basis of most compensation formulas.
- Conversion factor
- The dollar multiplier CMS applies to total RVUs to produce a payment. It is set annually, is budget-neutral by statute, and its trajectory is why a practice can see more patients each year and collect less per visit.
- Medicare Physician Fee Schedule (MPFS)
- The annual CMS rule setting payment for physician services. It anchors commercial contracts too, most of which are written as a percentage of Medicare, so an MPFS cut propagates well beyond Medicare volume.
- MACRA and MIPS
- MACRA replaced the sustainable growth rate with the Quality Payment Program; MIPS scores clinicians on quality, cost, improvement activities and interoperability and applies a payment adjustment two years later. Small practices carry disproportionate reporting burden relative to the adjustment at stake.
- Value-based contract
- A payer agreement tying part of payment to quality, cost or outcome performance rather than volume alone, ranging from small quality bonuses to full capitation with downside risk.
- Capitation
- A fixed per-member-per-month payment covering a defined scope of care regardless of utilization. It inverts the economics: an avoided visit becomes margin rather than lost revenue, which changes staffing, access and outreach design entirely.
- Shared savings
- An arrangement in which a practice or group shares in the difference between actual and benchmark spend for an attributed population, subject to quality gates. Upside-only and two-sided variants carry very different balance-sheet requirements.
- Risk adjustment and HCC coding
- Hierarchical Condition Categories map diagnoses to expected cost, adjusting payment for population morbidity. Accurate, documented and annually recaptured diagnosis coding determines revenue in any risk contract — and unsupported coding is a leading False Claims Act theory.
- RAF score
- Risk Adjustment Factor — the composite score expressing an attributed population's expected cost relative to average. It multiplies the benchmark, so a small RAF error moves large dollars.
- Prior authorization
- A payer requirement that a service be approved before delivery. It is the dominant administrative burden in outpatient care, a primary driver of care delay and abandonment, and the subject of active federal rulemaking and industry commitments.
- Referral and network adequacy
- The standards requiring a plan's network to provide sufficient provider access within distance and appointment-wait limits. Adequacy gaps are the practical opening through which a new practice gets into a closed panel.
- Credentialing and payer enrollment
- Verifying a clinician's licensure, training and history and enrolling them with each payer. Commonly runs 60 to 180 days, and every day before the effective date is a day a productive clinician generates no billable revenue.
- Clean claim rate and first-pass resolution
- The share of claims accepted without edits, and the share paid on first submission. Together they are the cleanest single read on whether front-desk, coding and billing operations are actually working.
- Denial rate
- The proportion of claims denied on submission. What matters operationally is the split between technical denials, which are preventable at registration, and clinical denials, which are an authorization and documentation problem.
- Days in AR
- Average days from service to payment. The standard liquidity measure for a practice, usually watched alongside the percentage of AR aged beyond 90 and 120 days.
- Net collection rate
- Payments collected as a share of what was collectible after contractual adjustments. It isolates how much of the earned, allowable revenue the practice actually captures, separate from how favorable its contracts are.
- No-show rate
- The share of scheduled appointments not kept. Each no-show is unrecoverable capacity, and reduction programs — reminders, waitlists, overbooking, deposits — are among the highest-ROI operational projects available to a clinic.
- Panel size
- The number of patients for whom a primary care clinician is responsible. It sets the ceiling on revenue in a capitated model and the ceiling on access in any model; too large and access collapses, too small and the economics do.
- Third next available appointment and access
- The industry-standard access measure is days until the third open slot rather than the first, because the first two often reflect cancellations - it reveals real access instead of flattering it. Access itself is the composite of appointment availability, hours, location, language, transportation, insurance acceptance and cost that determines whether a patient can actually be seen, and in outpatient marketing access is usually the product.
- Throughput and provider productivity
- Visit cycle time from arrival to departure and the visits or wRVUs a clinician generates per session. Rooming ratios, documentation burden and in-basket volume move both, which is why ambient documentation is evaluated as a capacity project rather than a software purchase.
- Scope of practice (NP/PA)
- What a nurse practitioner or physician assistant may legally do, which varies substantially by state. It governs care-team design, staffing cost and how a practice can extend access without adding physicians.
- Texas supervision and delegation
- Texas is a delegated-authority state: advanced practice providers prescribe under a physician's delegation through a prescriptive authority agreement, with defined supervision, chart review and site requirements. It constrains how many APPs a physician can support and where they can be located.
- ASC accreditation and case mix
- Ambulatory surgery centers are licensed by the state, Medicare-certified, and typically accredited by AAAHC, the Joint Commission or another CMS-deemed body. Case mix — which CPT codes at what payer mix — determines whether the center's economics work, because ASC rates run well below hospital outpatient rates for the same procedure.
- Direct primary care (DPC) membership
- A model in which a patient pays the practice a recurring fee for defined primary care services, with insurance billed for little or nothing. Small panels, long visits, transparent pricing; the regulatory line to watch is not becoming an unlicensed insurance product.
- Cash-pay and price transparency
- Publishing self-pay prices and honoring them. Beyond the marketing advantage, federal law requires most providers to give uninsured and self-pay patients a good faith estimate in advance, so vague pricing is now a compliance gap as well as a conversion problem.
- FQHC and the PPS rate
- A federally qualified health center receives an all-inclusive prospective payment system rate per qualifying encounter rather than fee-for-service payment, in exchange for HRSA requirements on governance, service scope and serving all patients regardless of ability to pay.
- 340B eligibility
- The federal drug pricing program letting qualifying safety-net providers, including FQHCs, buy outpatient drugs at steep discounts. For many health centers the 340B margin is what funds services no payer reimburses.
- Sliding fee scale
- The income-based discount schedule an FQHC must offer, tied to federal poverty guidelines, so that no patient is turned away for inability to pay. It is a condition of the grant and of the health center's designation, not a courtesy.