CPCS CPCS - Certified Provider Credentialing Specialist Reappointment and Recredentialing Questions and Answers 2 — Questions and Answers
Question 1: What is the standard maximum interval for medical staff reappointment under TJC standards?
- One year
- Two years (Correct answer)
- Three years
- Five years
Correct answer: Two years
The Joint Commission requires that medical staff reappointment occur at intervals not to exceed two years, though organizations may have shorter reappointment cycles.
TJC MS.06.01.05 requires that medical staff appointments be renewed at intervals that do not exceed 2 years. This reappointment cycle includes review of the practitioner's credentials, performance during the appointment period (OPPE data), and any changes in status (license, insurance, sanctions). Health plans credentialed under NCQA standards have a 3-year recredentialing cycle. The TJC 2-year hospital reappointment cycle and NCQA 3-year health plan recredentialing cycle are both industry standards but apply to different settings.
Question 2: Which of the following is typically included in a hospital reappointment review that is NOT required for initial appointment?
- Primary source verification of medical education
- Primary source verification of current medical license
- Review of OPPE data and peer review findings from the current appointment period (Correct answer)
- Peer recommendations from practitioners who know the applicant
Correct answer: Review of OPPE data and peer review findings from the current appointment period
Reappointment reviews must include assessment of the practitioner's clinical performance at the facility during the current appointment period (OPPE data, peer review findings, quality indicators), information that does not exist at initial appointment.
At reappointment, in addition to updated credential verifications, the review must include assessment of the practitioner's actual performance during the current appointment period. This performance data includes: OPPE reports and metrics, peer review case findings, quality indicators (infection rates, complication rates, etc.), adherence to medical staff policies (medical record completion, committee attendance), and any FPPE findings. This performance review is the distinctive element of reappointment that does not exist at initial appointment, where only credentials and training can be evaluated.
Question 3: A practitioner's reappointment is up for renewal, but their malpractice insurance expired 2 weeks ago. The practitioner states they are switching carriers and the new policy will be effective in 10 days. What is the appropriate action?
- Grant immediate reappointment with a note about the insurance gap
- Extend the current appointment for 10 days pending verification of new insurance, or consider temporary suspension if the policy allows (Correct answer)
- Deny reappointment until a full new credentialing cycle is completed
- Contact the NPDB to report the lapse
Correct answer: Extend the current appointment for 10 days pending verification of new insurance, or consider temporary suspension if the policy allows
A brief insurance gap during a carrier transition may be handled by extending the current appointment pending verification of new coverage, or requiring the practitioner to cease practice until coverage is confirmed, depending on medical staff policy.
An active malpractice insurance policy is typically a mandatory requirement for medical staff appointment. When a brief lapse occurs during a carrier transition, most medical staff bylaws provide for: (1) a brief extension of the current appointment period pending verification of new coverage, or (2) temporary suspension of privileges until coverage is confirmed. The specialist should document the situation, obtain evidence of the pending new policy (binder/commitment letter), verify the new policy when issued, and complete the reappointment process once valid coverage is confirmed. This should never result in a permanent denial for what is an administrative timing issue.
Question 4: Under NCQA health plan credentialing standards, which of the following is required at recredentialing (every 3 years) that is NOT explicitly required for ongoing monitoring between cycles?
- OIG LEIE exclusion check
- Practitioner application or profile update with current attestation (Correct answer)
- Monthly license database checks
- NPDB query upon receipt of adverse information
Correct answer: Practitioner application or profile update with current attestation
NCQA requires a current practitioner application or profile update with a new attestation at recredentialing, ensuring all information is current and re-attested. This is a formal recredentialing requirement distinct from ongoing monitoring activities.
At recredentialing, NCQA requires organizations to obtain and review: a current application or updated CAQH ProView profile with re-attestation, primary source verifications (no older than 180 days at the time of the committee decision), NPDB query, OIG LEIE/SAM.gov check, and peer references or OPPE data. The formal re-application/re-attestation process is a formal recredentialing requirement that serves to update all practitioner information and obtain a fresh sworn statement. Ongoing monitoring between cycles focuses on real-time tracking of specific changes (exclusions, license actions) rather than comprehensive re-verification.
Question 5: What is the recommended minimum advance notice to send reappointment packets to practitioners to ensure the process is completed before the current appointment expires?
- 2 weeks
- 30 days
- 90 to 120 days (Correct answer)
- 6 months
Correct answer: 90 to 120 days
Best practice is to begin the reappointment process 90-120 days before the appointment expiration to allow adequate time for application completion, verification, and committee review before expiration.
The reappointment process involves multiple time-consuming steps: (1) sending and receiving completed practitioner applications (often requires multiple follow-ups), (2) conducting all required primary source verifications, (3) obtaining NPDB queries and exclusion checks, (4) compiling and reviewing OPPE data, (5) scheduling and conducting credentials committee review, (6) MEC review, and (7) governing board approval. Beginning this process 90-120 days before appointment expiration provides adequate time for all steps while allowing buffer for follow-up on missing documents. Starting less than 60 days before expiration creates risk of lapsing appointments.
Question 6: At reappointment, an OPPE review reveals that a practitioner's case complication rate is significantly above the peer comparison benchmark. What is the appropriate credentialing action?
- Deny reappointment automatically based on the statistical finding
- Initiate FPPE for the practitioner to further evaluate the performance concern before making a reappointment decision (Correct answer)
- Reappoint with standard privileges without additional review
- Refer the matter to the hospital's compliance department rather than credentials committee
Correct answer: Initiate FPPE for the practitioner to further evaluate the performance concern before making a reappointment decision
Statistical outliers in OPPE data should trigger FPPE to further investigate the performance concern through focused monitoring before a reappointment decision is made.
When OPPE data reveals that a practitioner is a statistical outlier for an adverse metric (high complication rate, infection rate, etc.), the appropriate response is to initiate FPPE (Focused Professional Practice Evaluation) to further examine the concern. FPPE provides a structured, defined period of enhanced monitoring to determine whether the statistical finding reflects a genuine quality concern or a statistical artifact (case mix complexity, coding issues, etc.). The results of the FPPE then inform the reappointment decision. Automatic denial based solely on statistics, without investigation, would be premature and potentially unfair to the practitioner.
CPCS CPCS - Certified Provider Credentialing Specialist Reappointment and Recredentialing Questions and Answers 2
What is the standard maximum interval for medical staff reappointment under TJC standards?