CPCS CPCS - Certified Provider Credentialing Specialist Medical Staff Governance Questions and Answers 2 — Questions and Answers
Question 1: The medical staff bylaws at a hospital have a provision that conflicts with a newly enacted state law regarding credentialing timelines. Which takes precedence?
- The medical staff bylaws, because they are the governing document for the medical staff
- The state law, because state law supersedes organizational policies (Correct answer)
- The accreditation standards, because they supersede both bylaws and state law
- The hospital's administrative policy, which can override both
Correct answer: The state law, because state law supersedes organizational policies
State law takes precedence over organizational policies, including medical staff bylaws. Bylaws must be updated to comply with applicable state and federal laws.
The hierarchy of authority in healthcare organizations is: federal law, then state law, then accreditation standards, then hospital bylaws/policies. When a conflict exists between medical staff bylaws and state law, the state law prevails. The bylaws would need to be amended to comply with the new state requirement. Medical staff offices and legal counsel should regularly review bylaws for compliance with current law and update them as needed. Accreditation standards typically set minimum requirements that organizations may exceed but cannot fall below, and they too must comply with applicable law.
Question 2: What is the primary function of the Medical Executive Committee (MEC) in the credentialing process?
- To conduct primary source verification of all credentials
- To make final credentialing decisions that are then recommended to the governing board (Correct answer)
- To manage the day-to-day operations of the medical staff office
- To directly supervise all practitioners during provisional periods
Correct answer: To make final credentialing decisions that are then recommended to the governing board
The MEC receives credentialing committee recommendations, reviews them, and makes final medical staff recommendations to the governing board for final approval. The governing board retains ultimate authority.
In the governance hierarchy, the Medical Executive Committee is the highest authority of the organized medical staff and is responsible for: (1) receiving and acting on credentialing committee recommendations, (2) making final medical staff recommendations to the governing board regarding appointments, reappointments, and privileges, and (3) overseeing medical staff compliance with bylaws. The governing board retains ultimate fiduciary authority and must act on MEC recommendations, though it typically follows them. The MEC does not conduct PSV or daily operations, those are medical staff office functions.
Question 3: A practitioner who has been denied privileges invokes their right to a fair hearing. Under HCQIA, what protection does this invoke for the hospital?
- The hospital is immune from any litigation related to the credentialing decision
- HCQIA immunity from damages applies if the hospital followed the required fair hearing process and the action was taken for legitimate reasons (Correct answer)
- The practitioner forfeits their right to appeal to state courts by invoking HCQIA
- The hospital must pay the practitioner's legal fees during the hearing
Correct answer: HCQIA immunity from damages applies if the hospital followed the required fair hearing process and the action was taken for legitimate reasons
HCQIA provides immunity from damages to hospitals that conduct peer review and adverse actions according to the Act's standards, including providing adequate notice and fair hearing procedures, if the action was taken for patient safety reasons.
The Health Care Quality Improvement Act (HCQIA) provides immunity from monetary damages for professional review actions when: (1) the action was taken in the reasonable belief that it furthered quality health care, (2) reasonable efforts were made to obtain facts, (3) adequate notice and hearing procedures were provided or waived, and (4) there was a reasonable belief that the action was warranted. This immunity protects hospitals and peer reviewers from damages in discrimination and antitrust suits. It does not eliminate all litigation risk and does not prevent injunctive relief.
Question 4: Medical staff bylaws typically address which of the following regarding categories of medical staff membership?
- The salary scale for various staff categories
- The types of membership (active, associate, courtesy, consulting, etc.) and associated rights and privileges (Correct answer)
- The insurance premium rates for each membership category
- The number of patients each category must see annually
Correct answer: The types of membership (active, associate, courtesy, consulting, etc.) and associated rights and privileges
Medical staff bylaws define the categories of medical staff membership (active, associate, courtesy, consulting, honorary, etc.) and specify the rights, responsibilities, and privileges associated with each category.
Medical staff bylaws typically define membership categories such as: Active (full privileges, voting rights, committee obligations), Associate (provisional status, may have limited privileges), Courtesy (occasional privileges, no voting rights), Consulting (specific consultation privileges only), and Honorary (emeritus status, no clinical privileges). Each category has defined requirements for maintaining membership, voting rights, committee responsibilities, and privilege limitations. The bylaws also typically specify the pathway for changing from one category to another.
Question 5: Which document typically outlines the specific clinical privileges available at a hospital and the criteria required to obtain them?
- The medical staff bylaws
- The credentialing and privileging policies and procedures
- The delineation of privileges form (Correct answer)
- The hospital's administrative policy manual
Correct answer: The delineation of privileges form
The delineation of privileges form (or privilege delineation form) lists the specific clinical procedures and privileges available at the hospital along with the criteria required to obtain each one.
The delineation of privileges form (sometimes called the privilege list, privilege checklist, or privilege form) is a specialty-specific document that lists all clinical procedures and privileges available at the hospital for a given specialty, along with the minimum criteria (training, case volume, board certification, etc.) required to obtain each privilege. Practitioners complete this form to request specific privileges. The form is developed by the relevant clinical department and approved by the credentials committee and MEC. Bylaws address governance structure, not specific privilege criteria.
Question 6: Under most medical staff bylaws, what is the practitioner's responsibility regarding changes in licensure status that occur between credentialing cycles?
- Practitioners must wait until recredentialing to report changes
- Practitioners have an affirmative duty to immediately report any changes in licensure, DEA, insurance, or adverse actions to the medical staff office (Correct answer)
- Practitioners only need to report changes if they result in full license revocation
- Reporting responsibility rests solely with the state licensing board
Correct answer: Practitioners have an affirmative duty to immediately report any changes in licensure, DEA, insurance, or adverse actions to the medical staff office
Most medical staff bylaws require practitioners to immediately notify the medical staff office of any changes to licensure, DEA certification, malpractice insurance, hospital privileges elsewhere, or adverse actions, as a condition of medical staff membership.
Medical staff bylaws universally include provisions requiring practitioners to promptly report changes that affect their credentialing status. These typically include: any adverse action by a state licensing board, DEA certificate action, loss or restriction of malpractice insurance, adverse privilege actions at other institutions, criminal charges or convictions, and any changes that might affect clinical competence. Failure to report is typically grounds for summary suspension. This self-reporting obligation is separate from the organization's own monitoring obligations.
CPCS CPCS - Certified Provider Credentialing Specialist Medical Staff Governance Questions and Answers 2
The medical staff bylaws at a hospital have a provision that conflicts with a newly enacted state law regarding credentialing timelines.
Which takes precedence?