CPCS - Certified Provider Credentialing Specialist Accreditation Standards and Compliance Questions and Answers — Questions and Answers
Question 1: A rural hospital (originating site) enters into a written agreement to use a neurology group from a distant-site, TJC-accredited hospital. To comply with CMS Conditions of Participation for credentialing by proxy, which of the following is required?
- The originating site must re-verify the neurologist's medical license and DEA certificate from the primary source.
- The originating site's medical staff must review and recommend the neurologist for privileges based on performance data from the distant-site hospital.
- The distant-site hospital must be a Medicare-participating hospital and provide a list of the neurologist's current privileges. (Correct answer)
- The neurologist must be a member of the originating site's medical staff before telemedicine services can be provided.
Correct answer: The distant-site hospital must be a Medicare-participating hospital and provide a list of the neurologist's current privileges.
According to CMS Conditions of Participation (42 CFR §482.22), when credentialing by proxy for telemedicine, the originating-site hospital can rely on the distant-site hospital's credentialing decisions if there is a written agreement. This agreement must ensure that the distant-site hospital is a Medicare-participating hospital and that it provides the originating-site hospital with a current list of the practitioner's privileges.
Question 2: A hospital activates its emergency operations plan due to a mass casualty event. A volunteer physician arrives to help. According to The Joint Commission (TJC) standards for disaster privileges, which two items are the minimum necessary for the hospital to verify before granting the physician privileges?
- Board certification and DEA registration.
- A valid government-issued photo ID and a current, valid license. (Correct answer)
- Medical school diploma and two peer references.
- NPDB query results and malpractice insurance face sheet.
Correct answer: A valid government-issued photo ID and a current, valid license.
The Joint Commission standard EM.02.02.13 outlines a streamlined process for granting disaster privileges. The absolute minimum verification required is a valid government-issued photo ID (e.g., driver's license, passport) to confirm identity and at least one primary source verification of a credential, which is most often the practitioner's current license to practice.
Question 3: A Managed Care Organization (MCO) delegates the verification of provider credentials to a CVO. According to NCQA standards, which of the following responsibilities must the MCO ultimately retain?
- The primary source verification of state licensure.
- The final authority to make all credentialing decisions. (Correct answer)
- The collection of initial applications from providers.
- The semi-annual audit of the CVO's credentialing files.
Correct answer: The final authority to make all credentialing decisions.
While NCQA allows for the delegation of credentialing tasks like primary source verification, it explicitly states that the delegating organization (the MCO) must retain the final authority and responsibility for all credentialing decisions. This critical function cannot be delegated.
Question 4: A physician is notified that the Medical Executive Committee has recommended the termination of their clinical privileges due to quality of care concerns. Under the Health Care Quality Improvement Act (HCQIA), the physician is entitled to which of the following?
- A monetary settlement from the hospital.
- An immediate report to the National Practitioner Data Bank (NPDB).
- A fair hearing and appellate review process. (Correct answer)
- A mandatory transfer to a non-clinical position.
Correct answer: A fair hearing and appellate review process.
The Health Care Quality Improvement Act (HCQIA) provides immunity to healthcare entities for peer review actions but requires that they provide due process to the affected practitioner. This includes adequate notice and the right to a fair hearing and an appellate review process before a final adverse action is taken and reported.
Question 5: A hospital needs to grant temporary privileges to a locum tenens physician to fill an urgent and unexpected vacancy. According to The Joint Commission (TJC), which of the following must be completed BEFORE the physician begins work?
- Verification of all training and education from primary sources.
- Receipt of all peer references as listed on the application.
- Verification of a current, valid license and a query of the NPDB. (Correct answer)
- Approval by the hospital's governing body at its next scheduled meeting.
Correct answer: Verification of a current, valid license and a query of the NPDB.
The Joint Commission allows for the granting of temporary privileges to meet an important patient care need. However, before these privileges can be exercised, the hospital must, at a minimum, verify that the practitioner has a current, valid license and must query the National Practitioner Data Bank (NPDB). This ensures basic safety standards are met even in an expedited process.
Question 6: Which of the following activities is a required component of a health plan's ongoing monitoring process to comply with NCQA standards?
- Reviewing annual patient satisfaction surveys for each provider.
- Conducting a full background check on each provider every six months.
- Tracking provider licensure sanctions between recredentialing cycles. (Correct answer)
- Verifying board certification status on a quarterly basis.
Correct answer: Tracking provider licensure sanctions between recredentialing cycles.
NCQA standards require organizations to have a process for ongoing monitoring of specific data points between the 36-month recredentialing cycles. This includes, but is not limited to, monitoring Medicare/Medicaid sanctions and actions against the provider's license issued by state licensing boards to identify any potential quality of care issues.
CPCS - Certified Provider Credentialing Specialist Accreditation Standards and Compliance Questions and Answers
A rural hospital (originating site) enters into a written agreement to use a neurology group from a distant-site, TJC-accredited hospital.
To comply with CMS Conditions of Participation for credentialing by proxy, which of the following is required?