A
AHCA
Agency for Health Care Administration
Florida's primary healthcare regulatory agency responsible for licensing, inspecting, and overseeing healthcare facilities including hospitals, nursing homes, and PPEC centers. AHCA enforces state and federal healthcare standards and manages Florida Medicaid.
Every PPEC center and medical practice in Florida must be licensed through AHCA — understanding their requirements is foundational.
APR-DRG
All Patient Refined Diagnosis-Related Group
A classification system that categorizes hospital patients into clinically meaningful groups based on diagnosis, severity of illness, and risk of mortality. Used to determine payment rates for inpatient hospital services.
Relevant for practice owners who refer patients to hospitals or need to understand hospital reimbursement structures.
ARNP
Advanced Registered Nurse Practitioner
A registered nurse with advanced graduate-level education and clinical training who can diagnose conditions, prescribe medications, and manage patient care independently or collaboratively. In Florida, ARNPs have expanded practice authority under recent legislation.
ARNPs can serve critical clinical roles in both medical practices and PPEC centers, potentially reducing physician staffing costs.
Authorization (Prior Authorization)
Also known as PA or Pre-Auth
A requirement from health insurance plans that a provider must obtain advance approval before delivering specific services, procedures, or medications. The insurer evaluates whether the requested service meets medical necessity criteria before authorizing coverage.
PPEC admissions and many specialized medical services require prior authorization — delays here directly impact revenue and patient access.
B
Background Screening (Level 2)
Level 2 Background Check
A comprehensive fingerprint-based criminal background check required by Florida law for all healthcare workers who have direct contact with patients. Level 2 screening includes FBI and FDLE databases and is more extensive than a standard background check.
Every employee in your PPEC center or medical practice must pass Level 2 screening before patient contact — plan for processing time during hiring.
Billing Code
CPT / HCPCS Codes
Standardized numeric codes used to identify specific medical services, procedures, and supplies when submitting claims to insurance companies. The two main systems are CPT (Current Procedural Terminology) and HCPCS (Healthcare Common Procedure Coding System).
Accurate billing code selection directly determines your reimbursement — incorrect coding is a leading cause of claim denials and compliance issues.
Business Associate Agreement (BAA)
BAA
A legally binding contract required under HIPAA between a healthcare provider and any vendor or partner who handles protected health information (PHI). The agreement ensures the business associate will appropriately safeguard patient data.
You must have BAAs in place with every vendor that touches patient data — EHR providers, billing companies, IT consultants, and more.
C
Census (Patient Census)
Daily Census / Average Daily Census (ADC)
The count of patients receiving services at a facility at a given time or on a given day. Average daily census (ADC) tracks this over time and is a critical metric for operational planning, staffing, and revenue forecasting.
Your PPEC center's census directly drives revenue — building and maintaining census is the single most important operational metric after licensure.
CHIP
Children's Health Insurance Program
A federal-state partnership that provides health coverage to uninsured children in families with incomes too high for Medicaid but too low to afford private insurance. In Florida, CHIP is administered as part of the Florida KidCare program.
Many PPEC-eligible children are covered through CHIP or Medicaid — understanding both programs is essential for enrollment and billing.
CLIA
Clinical Laboratory Improvement Amendments
Federal regulations that establish quality standards for all laboratory testing performed on human specimens to ensure accuracy, reliability, and timeliness of results. Any practice performing lab tests — even simple point-of-care tests — must have a CLIA certificate.
If your practice performs any lab testing (glucose, urine, strep tests), you need the appropriate CLIA waiver or certificate before testing.
CMS
Centers for Medicare & Medicaid Services
The federal agency within the U.S. Department of Health and Human Services that administers Medicare, Medicaid, CHIP, and the Health Insurance Marketplace. CMS sets national healthcare policies, reimbursement rates, and quality standards.
CMS regulations and policies set the overarching framework that every healthcare practice must operate within.
CON
Certificate of Need
A regulatory process in some states requiring healthcare providers to obtain state approval before building new facilities, expanding capacity, or offering certain services. Florida repealed most CON requirements but retains them for select services.
While Florida has largely eliminated CON requirements, it is important to verify whether your specific facility type or service line still requires one.
Compliance Program
Healthcare Compliance Program
A structured system of internal policies, procedures, training, and monitoring designed to ensure a healthcare organization adheres to all applicable laws, regulations, and ethical standards. Required elements include a compliance officer, written standards, training, auditing, and enforcement mechanisms.
A robust compliance program protects your practice from regulatory penalties, fraud allegations, and loss of licensure.
CPT
Current Procedural Terminology
A standardized medical code set maintained by the American Medical Association (AMA) used to describe medical, surgical, and diagnostic services. CPT codes are the universal language for communicating procedures and services to payers for reimbursement.
Correct CPT coding is essential for clean claims submission — your billing team must stay current with annual code updates.
Credentialing
Provider Credentialing / Enrollment
The process of verifying a healthcare provider's qualifications — including education, training, licensure, certifications, and work history — to authorize them to provide care within a facility or bill insurance companies. Also refers to enrolling providers with insurance networks.
Credentialing typically takes 90–120 days per payer — start this process early to avoid revenue delays when your practice opens.
D
DEA
Drug Enforcement Administration
A federal agency that enforces controlled substance laws. Healthcare providers who prescribe, dispense, or administer controlled substances must register with the DEA and obtain a unique DEA number. Facilities that store controlled substances also need registration.
If your practice or PPEC center handles any controlled substances, DEA registration is mandatory — apply early as processing takes several weeks.
Deficiency (Survey Deficiency)
AHCA Survey Deficiency / Citation
A finding by a regulatory surveyor (such as AHCA) that a healthcare facility is not in compliance with a specific regulation or standard. Deficiencies are documented during licensure surveys and require a plan of correction. Severity ranges from minor to immediate jeopardy.
Understanding common deficiency areas helps you prepare proactively — DDI Resources provides mock survey prep to minimize deficiency risk.
DRG
Diagnosis-Related Group
A patient classification system that groups hospital inpatient cases into categories based on diagnosis, procedures performed, age, and other factors. DRGs determine how much Medicare and other payers reimburse hospitals for inpatient stays.
While DRGs primarily affect hospitals, understanding them helps practice owners communicate effectively about referral patterns and care transitions.
E
EHR
Electronic Health Record
A comprehensive digital version of a patient's medical chart that provides real-time, patient-centered records accessible to authorized providers across organizations. EHR systems include clinical data, treatment history, lab results, medications, and care plans.
Choosing the right EHR system is one of the most impactful technology decisions you will make — it affects clinical workflow, billing, and compliance.
EIN
Employer Identification Number
A unique nine-digit number assigned by the IRS to business entities for tax identification purposes. Also known as a Federal Tax Identification Number. Required for opening business bank accounts, hiring employees, and filing tax returns.
Your EIN is one of the very first things you will obtain when forming your practice entity — it is needed for nearly every subsequent step.
EMR
Electronic Medical Record
A digital version of a patient's chart within a single practice or organization. Unlike EHRs, EMRs are typically not designed to share information across organizations. The terms EMR and EHR are often used interchangeably, though they have distinct meanings.
Whether you choose an EMR or full EHR depends on your practice size and interoperability needs — both must meet HIPAA requirements.
Encounter (Patient Encounter)
Clinical Encounter / Visit
A single interaction between a patient and a healthcare provider for the purpose of providing healthcare services. Each encounter generates documentation and may result in billable charges. In PPEC, each daily attendance constitutes an encounter.
Proper encounter documentation is the foundation of compliant billing — every service rendered must be accurately captured.
EOB
Explanation of Benefits
A document from an insurance company to a patient or provider detailing how a claim was processed, including the amount billed, the amount allowed, the amount paid, and any patient responsibility. An EOB is not a bill but rather an explanation of payment decisions.
Reading EOBs correctly helps you identify underpayments, denials, and billing issues that directly impact your practice's revenue.
F
Fee Schedule
Provider Fee Schedule / Reimbursement Schedule
A complete list of fees used by Medicare, Medicaid, or private insurers to pay healthcare providers for specific services. Fee schedules list each covered service alongside its corresponding reimbursement amount. They vary by payer, geographic region, and provider type.
Understanding fee schedules for your area and specialty is essential for financial projections and determining practice viability.
FQHC
Federally Qualified Health Center
Community-based healthcare organizations that receive federal funding to provide primary care services in underserved areas, regardless of patients' ability to pay. FQHCs receive enhanced Medicaid and Medicare reimbursement rates and must meet strict federal requirements.
FQHCs are often referral partners for PPEC centers and understanding their role can help with patient sourcing and community partnerships.
FTE
Full-Time Equivalent
A unit of measurement that represents the workload of one full-time employee. One FTE equals 40 hours per week or 2,080 hours per year. Two half-time employees equal one FTE. Used for staffing calculations, budgeting, and regulatory compliance.
Calculating FTEs correctly is critical for meeting staffing ratio requirements and accurately budgeting labor costs.
G
General Liability Insurance
Commercial General Liability (CGL)
Insurance that protects a business against claims of bodily injury, property damage, and personal injury occurring on your premises or as a result of your operations. This is distinct from professional liability (malpractice) insurance, which covers clinical errors.
General liability insurance is required for AHCA licensure and is a baseline requirement for any healthcare facility — secure it early in your startup process.
H
HCBS
Home and Community-Based Services
Medicaid-funded services that allow individuals to receive care in their homes or communities rather than in institutional settings like hospitals or nursing facilities. HCBS programs are authorized through Medicaid waivers and can include PPEC as a covered service.
PPEC centers operate within the HCBS framework — understanding this helps you position your center and navigate Medicaid waiver programs.
HEDIS
Healthcare Effectiveness Data and Information Set
A widely used set of performance measures developed by NCQA that evaluates how well health plans and providers deliver care. HEDIS measures cover areas like preventive care, chronic disease management, access to care, and patient satisfaction.
Managed care plans track HEDIS scores and may tie reimbursement incentives to performance — meeting HEDIS measures can boost your revenue.
HIPAA
Health Insurance Portability and Accountability Act
A landmark federal law enacted in 1996 that establishes national standards for protecting sensitive patient health information (PHI) from disclosure without patient consent. HIPAA includes the Privacy Rule, Security Rule, and Breach Notification Rule, and applies to all healthcare providers and their business associates.
HIPAA compliance is non-negotiable — violations carry fines up to $1.5 million per category and can result in criminal charges.
HMO
Health Maintenance Organization
A type of health insurance plan that provides care through a network of contracted providers. HMO members typically need a referral from a primary care physician to see specialists, and services outside the network are generally not covered except in emergencies.
Many Medicaid managed care plans in Florida operate as HMOs — your PPEC or practice must be in-network to serve their members.
I
ICD-10
International Classification of Diseases, 10th Revision
The global standard for classifying diseases, health conditions, and causes of death using alphanumeric codes. ICD-10-CM (Clinical Modification) is used in the United States for diagnosis coding on insurance claims. It contains over 70,000 codes for precise clinical documentation.
Accurate ICD-10 coding is required on every claim — incorrect codes lead to denials and can trigger audits.
Incident Report
Occurrence Report / Event Report
A formal written document that records any unusual event, accident, injury, or near-miss that occurs within a healthcare facility. Incident reports are a key component of risk management and quality improvement programs, and certain incidents must be reported to AHCA.
Having a clear incident reporting protocol protects your facility legally and is required during AHCA surveys.
L
Level 2 Background Screening
Fingerprint-Based Background Check (FDLE/FBI)
Florida's comprehensive criminal background check that uses fingerprint-based searches of both the Florida Department of Law Enforcement (FDLE) and FBI databases. Required for all healthcare workers with direct patient access under Florida Statute 408.809.
Budget 2–4 weeks for Level 2 screening results — no employee may have patient contact until cleared.
Licensure Survey
AHCA Initial or Renewal Licensure Survey
An on-site inspection conducted by AHCA surveyors to determine whether a healthcare facility meets all state and federal regulatory requirements for licensure. The initial licensure survey must be passed before a new facility can open. Renewal surveys occur periodically thereafter.
Passing the initial survey is the final hurdle before opening — DDI Resources provides mock surveys to ensure you pass the first time.
LPN
Licensed Practical Nurse
A licensed nurse who has completed a state-approved practical nursing program and passed the NCLEX-PN exam. LPNs provide basic nursing care under the supervision of RNs or physicians, including vital signs monitoring, medication administration, wound care, and patient documentation.
LPNs are essential staff members in PPEC centers and help maintain required nurse-to-patient ratios at a lower cost than RNs.
M
Managed Care Organization (MCO)
MCO
A health insurance entity that contracts with a network of providers to deliver healthcare services to its members. MCOs manage cost, quality, and access to care. In Florida, most Medicaid beneficiaries are enrolled in MCOs through the Statewide Medicaid Managed Care (SMMC) program.
Contracting with the right MCOs in your service area is critical for PPEC revenue — most of your patients will come through managed care plans.
Medicaid
Title XIX of the Social Security Act
A joint federal and state program that provides health coverage to eligible low-income individuals, families, children, pregnant women, elderly adults, and people with disabilities. In Florida, Medicaid is administered by AHCA and covers approximately 5 million residents. It is the primary payer for PPEC services.
Medicaid is the lifeblood of PPEC center revenue — successful Medicaid enrollment and managed care contracting are non-negotiable for operations.
Medical Director
Physician Medical Director
A licensed physician who provides clinical oversight and direction for a healthcare facility. The medical director is responsible for establishing clinical protocols, reviewing plans of care, ensuring quality of medical services, and serving as the clinical authority for the facility.
PPEC centers are required to have a medical director — securing the right physician early is essential for your licensure application.
Medical Necessity
Clinical / Medical Justification
The standard used by health insurers and regulators to determine whether a healthcare service is appropriate, reasonable, and required for diagnosing or treating a patient's condition. Services deemed not medically necessary may be denied coverage. Documentation of medical necessity is critical for claims approval.
Every PPEC admission and service must be supported by documented medical necessity — weak documentation is the top reason for claim denials.
Medicare
Title XVIII of the Social Security Act
A federal health insurance program primarily for Americans age 65 and older, as well as certain younger individuals with disabilities or end-stage renal disease. Medicare has four parts: Part A (hospital), Part B (medical), Part C (Medicare Advantage), and Part D (prescription drugs).
While PPEC serves children (Medicaid), Medicare enrollment may be relevant for general medical practices serving adult and senior populations.
Malpractice Insurance
Professional Liability Insurance
Insurance that protects healthcare providers and facilities against claims of negligence, errors, or omissions in professional services that result in patient harm. Policies can be occurrence-based (covering incidents during the policy period) or claims-made (covering claims filed during the policy period).
Malpractice insurance is required for AHCA licensure and credentialing — obtain coverage before hiring clinical staff or seeing patients.
N
NPI
National Provider Identifier
A unique 10-digit identification number issued by CMS to healthcare providers in the United States. There are two types: Type 1 NPI for individual providers and Type 2 NPI for organizations. NPIs are required for billing, claims submission, and all HIPAA-covered electronic transactions.
You will need both a Type 2 NPI for your facility and Type 1 NPIs for individual providers — apply as soon as your entity is formed.
Nurse-to-Patient Ratio
Staffing Ratio / Nurse Staffing Requirement
The regulated minimum number of licensed nurses (RNs and LPNs) required per number of patients in a healthcare facility. These ratios are set by state regulations and vary by facility type and patient acuity. PPEC centers must maintain specific ratios during all hours of operation.
Staffing ratios directly impact your labor budget and hiring plan — violating them during a survey can result in citations or license suspension.
O
OIG
Office of Inspector General
The division of the U.S. Department of Health and Human Services responsible for combating fraud, waste, and abuse in federal healthcare programs. The OIG maintains the List of Excluded Individuals/Entities (LEIE) — providers on this list cannot participate in Medicare or Medicaid.
Screen all employees and contractors against the OIG exclusion list before hiring and monthly thereafter — employing an excluded individual carries severe penalties.
OSHA
Occupational Safety and Health Administration
A federal agency that sets and enforces workplace safety and health standards. Healthcare facilities must comply with OSHA standards including bloodborne pathogen exposure control plans, hazard communication, personal protective equipment requirements, and workplace violence prevention.
OSHA compliance is required from day one — ensure your policies, training, and safety equipment meet all applicable standards.
P
PA (Prior Authorization)
Pre-Authorization / Pre-Cert
The process of obtaining advance approval from an insurance plan before providing specific healthcare services. The payer reviews clinical documentation to determine if the requested service meets medical necessity criteria. Without PA, claims may be denied even if the service was appropriate.
Efficient prior authorization processes are critical for PPEC admissions — build a dedicated workflow to prevent delays in patient enrollment.
Plan of Care
POC / Individualized Care Plan
A comprehensive, individualized document that outlines a patient's diagnoses, treatments, goals, and the specific services required. In PPEC, each child must have a physician-prescribed plan of care that details their medical needs, nursing interventions, therapy services, and measurable goals.
Plans of care are reviewed during every AHCA survey and are required for Medicaid billing — they must be current, signed, and clinically specific.
Plan of Correction (POC)
Corrective Action Plan
A written response submitted to a regulatory agency (like AHCA) after a survey identifies deficiencies. The plan describes the specific actions the facility will take to correct each deficiency, who is responsible, and the timeline for completion. AHCA must accept the POC before the issue is considered resolved.
Having a strong plan of correction framework ready in advance demonstrates operational maturity and speeds resolution of survey findings.
PPEC
Prescribed Pediatric Extended Care
A licensed healthcare model that provides medical daycare services for medically complex children (ages 0–21) who require skilled nursing care but can be safely managed outside a hospital setting. PPEC centers offer nursing care, therapies, developmental activities, and family respite in a structured medical environment.
PPEC is DDI Resources' flagship consulting specialty — we have hands-on operational experience and guide clients from concept through licensure.
PPO
Preferred Provider Organization
A type of health insurance plan that offers a network of preferred providers at lower costs but also covers out-of-network care at higher cost-sharing levels. Unlike HMOs, PPO members typically do not need referrals to see specialists.
Understanding PPO vs. HMO structures helps when contracting with commercial insurers and counseling patients on coverage.
Provider Enrollment
Payer Enrollment / Insurance Contracting
The process of registering a healthcare provider or facility with government programs (Medicaid, Medicare) and private insurance companies to become an authorized, in-network provider that can bill for services. This involves credentialing, application submission, contract negotiation, and site visits.
Start provider enrollment immediately after entity formation — delays here directly translate to delayed revenue once you open your doors.
Q
Quality Improvement (QI)
QI / Continuous Quality Improvement (CQI)
A systematic, ongoing process of identifying, analyzing, and improving clinical processes, patient outcomes, and operational efficiency within a healthcare organization. QI programs use data-driven methods like Plan-Do-Study-Act (PDSA) cycles to implement and measure improvements.
A documented QI program is required for licensure and accreditation — it also demonstrates to surveyors that your facility proactively addresses quality issues.
R
Reimbursement Rate
Payment Rate / Allowed Amount
The amount a health plan or government program pays a provider for a specific service. Reimbursement rates vary by payer, service type, geographic region, and provider type. For PPEC centers in Florida, Medicaid managed care reimbursement typically is $281.68 per child per full day (T1025).
Your reimbursement rates directly determine revenue potential — negotiate aggressively with MCOs and understand rate variation across plans.
RN
Registered Nurse
A licensed nurse who has completed a nursing education program (ADN or BSN) and passed the NCLEX-RN exam. RNs perform comprehensive patient assessments, develop care plans, administer medications, supervise LPNs and CNAs, and provide patient education. They have a broader scope of practice than LPNs.
PPEC centers must have RN coverage during all operating hours — they are your most important clinical hires and often the most challenging to recruit.
RVU
Relative Value Unit
A measure used by Medicare (and adopted widely by private payers) to determine the value of physician services. Each CPT code has an assigned RVU composed of three components: physician work, practice expense, and malpractice cost. RVUs are multiplied by a conversion factor to calculate payment amounts.
Understanding RVUs helps medical practice owners evaluate provider productivity, set compensation models, and forecast revenue.
S
Scope of Services
Service Scope / Service Line
A formal description of all the healthcare services a facility is licensed, equipped, and staffed to provide. The scope of services must align with your licensure category, staffing capabilities, and physical plant. It defines the boundaries of what your facility can and cannot do.
Clearly defining your scope of services before licensure prevents regulatory issues and ensures your facility design matches your clinical mission.
SMMC
Statewide Medicaid Managed Care
Florida's Medicaid delivery system in which most Medicaid beneficiaries are enrolled in managed care plans. SMMC has two components: Managed Medical Assistance (MMA) for general healthcare and Long-Term Care (LTC) for long-term services. PPEC services are covered under the MMA program.
Understanding Florida's SMMC structure is essential for identifying which managed care plans to contract with in your service area.
Survey (Licensure Survey)
AHCA Survey / State Survey
An official on-site inspection of a healthcare facility conducted by regulatory surveyors to assess compliance with applicable laws, rules, and standards. Surveys may be announced (initial licensure) or unannounced (renewal, complaint-driven). Surveyors review documentation, observe care, interview staff, and inspect the physical environment.
Survey preparation should begin months before your expected survey date — DDI Resources conducts mock surveys to identify and resolve gaps proactively.
T
Telehealth
Telemedicine / Virtual Care
The delivery of healthcare services remotely using telecommunications technology, including video consultations, remote patient monitoring, and secure messaging. Telehealth expanded significantly during the COVID-19 pandemic, and many states including Florida have established permanent telehealth practice standards.
Telehealth capabilities can expand your practice's reach and revenue — consider incorporating virtual visits into your service model from the start.
Third-Party Payer
Insurance Carrier / Health Plan
Any entity other than the patient that pays for healthcare services. Third-party payers include private insurance companies, Medicaid, Medicare, managed care organizations, and workers' compensation carriers. The term distinguishes the payer (insurer) from the first party (patient) and second party (provider).
Diversifying your third-party payer mix reduces financial risk — avoid over-reliance on a single plan for the majority of your revenue.
U
Utilization Review
UR / Utilization Management (UM)
A process used by health insurance plans to evaluate the appropriateness, medical necessity, and efficiency of healthcare services before, during, or after they are provided. Utilization review determines whether a service should be authorized, continued, or denied based on clinical evidence and plan criteria.
Managed care plans conduct utilization reviews on PPEC services — maintain thorough clinical documentation to support ongoing authorization.
W
Waiver Program (Medicaid Waiver)
Section 1915(c) Waiver / HCBS Waiver
Federal authorization that allows states to waive certain Medicaid requirements to provide home and community-based services (HCBS) as an alternative to institutional care. Waivers enable states to cover services like PPEC, home health, and respite care that would not otherwise be available under standard Medicaid. Florida operates several waiver programs serving different populations.
PPEC services are authorized through Medicaid waiver programs — understanding the waiver landscape helps you navigate eligibility and reimbursement.