CPCS Medical Staff Committee Support and Management 4 — Questions and Answers
Question 1: A credentialing specialist notices that a physician's reappointment file lacks a required peer reference. What is the correct action?
- Present the file to the committee with a note about the missing reference
- Place the file on hold and obtain the missing reference before presenting to the committee (Correct answer)
- Request the committee waive the requirement for this applicant
- Proceed with reappointment and collect the reference within 90 days
Correct answer: Place the file on hold and obtain the missing reference before presenting to the committee
Incomplete files should not be presented to the committee; the specialist must obtain all required documentation before the file proceeds to review.
Question 2: Which of the following best describes the role of the credentials committee versus the medical executive committee in the credentialing process?
- The credentials committee grants privileges; the MEC reviews appeals
- The credentials committee makes recommendations; the MEC acts on those recommendations (Correct answer)
- The credentials committee is advisory only; the MEC has sole decision-making authority
- Both committees have equal and independent authority to grant or deny privileges
Correct answer: The credentials committee makes recommendations; the MEC acts on those recommendations
The credentials committee evaluates applications and makes recommendations that are then reviewed and acted upon by the medical executive committee.
Question 3: What is the significance of the '30-day rule' commonly referenced in medical staff committee proceedings?
- Applicants must submit applications 30 days before the committee meeting
- Committees must act on complete applications within 30 days of receipt
- Physicians have 30 days to respond to a notice of adverse action (Correct answer)
- New privileges must be reviewed within 30 days of being exercised
Correct answer: Physicians have 30 days to respond to a notice of adverse action
Most medical staff bylaws and fair hearing policies give physicians 30 days to request a hearing after receiving notice of an adverse credentialing action.
Question 4: What is the purpose of a 'proctoring' or 'supervision' requirement attached to newly granted clinical privileges?
- To reduce the hospital's malpractice insurance premiums
- To allow observed evaluation of competency before independent practice is confirmed (Correct answer)
- To satisfy state licensing board requirements for new physicians
- To ensure the physician meets patient volume requirements
Correct answer: To allow observed evaluation of competency before independent practice is confirmed
Proctoring provides direct observation of a physician's clinical performance to validate competency before granting unrestricted independent privileges.
Question 5: Which accreditation standard requires hospitals to define the criteria used to evaluate clinical privilege requests?
- The National Practitioner Data Bank reporting rules
- The Joint Commission MS standard requiring criteria-based privileging (Correct answer)
- The CMS Conditions of Participation for staffing ratios
- The HIPAA Privacy Rule for credentialing records
Correct answer: The Joint Commission MS standard requiring criteria-based privileging
The Joint Commission MS standards require that hospitals establish and apply defined, criteria-based processes for evaluating privilege requests.
Question 6: When a physician is granted 'telemedicine privileges,' what unique credentialing consideration typically applies?
- Telemedicine practitioners must be licensed in the originating site's state (Correct answer)
- Telemedicine providers are exempt from credentialing requirements under federal law
- Only physicians licensed in the distant site state require credentialing
- Telemedicine privileges automatically expire after 90 days
Correct answer: Telemedicine practitioners must be licensed in the originating site's state
Telemedicine practitioners must hold licensure in the state where the patient is located (the originating site), adding a multi-state licensing dimension to credentialing.
Question 7: A committee is reviewing a physician's application and discovers an undisclosed malpractice settlement. What is the most appropriate next step?
- Automatically deny the application due to failure to disclose
- Request the physician provide a written explanation and review the circumstances before deciding (Correct answer)
- Forward the matter directly to the board of directors
- Approve the application provisionally pending a 90-day review
Correct answer: Request the physician provide a written explanation and review the circumstances before deciding
Due process requires that the physician be given the opportunity to explain an undisclosed item before the committee makes a final determination.
CPCS Medical Staff Committee Support and Management 4
A credentialing specialist notices that a physician's reappointment file lacks a required peer reference.
What is the correct action?