CPCS Regulatory Requirements and Law 2 — Questions and Answers
Question 1: Under the Health Care Quality Improvement Act (HCQIA), which condition must be met for a professional review action to receive immunity from damages?
- The action must be taken in the reasonable belief that it furthers quality healthcare (Correct answer)
- The action must result in a permanent revocation of privileges
- The practitioner must have been convicted of a criminal offense
- The hospital must have notified CMS prior to initiating the review
Correct answer: The action must be taken in the reasonable belief that it furthers quality healthcare
HCQIA immunity applies when the review action is taken in the reasonable belief that it furthers quality healthcare, adequate notice and hearing procedures are followed, and there is a reasonable effort to obtain the facts.
Question 2: Which federal law established the National Practitioner Data Bank (NPDB) and mandated reporting of certain adverse actions?
- Stark Law
- Health Care Quality Improvement Act of 1986 (Correct answer)
- Emergency Medical Treatment and Labor Act
- Anti-Kickback Statute
Correct answer: Health Care Quality Improvement Act of 1986
The Health Care Quality Improvement Act of 1986 (HCQIA) established the NPDB and created mandatory reporting requirements for malpractice payments and adverse privilege actions.
Question 3: A state medical board revokes a physician's license. Under HCQIA, within how many days must the board report this action to the NPDB?
- 15 days
- 30 days (Correct answer)
- 45 days
- 60 days
Correct answer: 30 days
State licensing boards must report adverse licensure actions to the NPDB within 30 days of the action being taken.
Question 4: Which accreditation standard requires hospitals to query the NPDB at the time of initial appointment and at reappointment?
- CMS Conditions of Participation (Correct answer)
- The Joint Commission Medical Staff Standards
- URAC Provider Credentialing Standards
- NCQA Credentialing Standards
Correct answer: CMS Conditions of Participation
CMS Conditions of Participation (42 CFR §482.12) require hospitals to query the NPDB when granting initial privileges and at reappointment.
Question 5: The Americans with Disabilities Act (ADA) requires credentialing organizations to make reasonable accommodations for practitioners with disabilities UNLESS doing so would cause:
- Any increase in administrative costs
- Undue hardship on the organization (Correct answer)
- The process to take longer than 90 days
- A deviation from accreditation standards
Correct answer: Undue hardship on the organization
The ADA requires reasonable accommodation unless it would create an undue hardship, meaning significant difficulty or expense relative to the organization's resources.
Question 6: Under EMTALA, which type of practitioner privilege decision could implicate the law if it results in a hospital being unable to staff its emergency department?
- Suspension of a physician's elective surgery privileges only
- Denial of privileges to an on-call specialist needed for emergency coverage (Correct answer)
- Failure to credential an advanced practice nurse for outpatient care
- Lapse of a physician's hospital affiliation due to non-renewal
Correct answer: Denial of privileges to an on-call specialist needed for emergency coverage
EMTALA requires hospitals to maintain adequate on-call coverage; denying privileges to specialists essential for emergency care could impair the hospital's ability to meet EMTALA obligations.
Question 7: Which legal concept protects peer review committee members from civil liability when they act in good faith during credentialing proceedings?
- Qualified privilege (Correct answer)
- Absolute privilege
- Sovereign immunity
- Promissory estoppel
Correct answer: Qualified privilege
Qualified privilege protects peer review participants from defamation claims when they share credentialing information in good faith within appropriate channels without malice.
CPCS Regulatory Requirements and Law 2
Under the Health Care Quality Improvement Act (HCQIA), which condition must be met for a professional review action to receive immunity from damages?