CPCS - Certified Provider Credentialing Specialist Regulatory Requirements and Law Questions and Answers Flashcards
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Which federal law established the National Practitioner Data Bank and the peer review reporting system?
Answer: HCQIA (Health Care Quality Improvement Act of 1986)
The Health Care Quality Improvement Act of 1986 (HCQIA) established the National Practitioner Data Bank and created the legal framework for peer review reporting and immunity.
Under the Social Security Act, what is the penalty for knowingly employing or contracting with an excluded individual for items or services billable to Medicare or Medicaid?
Answer: Civil monetary penalties of up to $20,000 per item or service rendered
Under the Civil Monetary Penalties Law (42 U.S.C. Section 1320a-7a), organizations can be assessed civil monetary penalties of up to $20,000 per item or service billed to Medicare or Medicaid that was rendered by an excluded individual.
Which federal law requires covered entities to verify, before making payment, that providers are not excluded from participation in federal healthcare programs?
Answer: Social Security Act, Section 1128 and 1156
Sections 1128 and 1156 of the Social Security Act establish the exclusion authorities and the requirement to deny payment for services rendered by excluded individuals.
The anti-kickback statute (42 U.S.C. Section 1320a-7b) has implications for credentialing when:
Answer: A hospital grants privileges based on referral volume rather than clinical qualifications
The anti-kickback statute prohibits inducements for referrals, including granting or maintaining privileges based on referral volume rather than clinical qualifications. Using privileges as a business incentive violates the statute.
Which federal regulation requires hospitals to notify the NPDB within 15 days of accepting a practitioner's voluntary surrender of privileges while under investigation?
Answer: HCQIA Section 11133
HCQIA Section 11133 (implemented at 42 CFR Part 60) requires hospitals to report to the NPDB when a practitioner voluntarily surrenders privileges while under investigation or to avoid investigation.
Under the Americans with Disabilities Act (ADA), which inquiry is permissible during the credentialing process?
Answer: Asking whether the practitioner currently has a physical or mental condition that impairs their ability to perform the essential functions of their clinical privileges, with or without reasonable accommodation
The ADA permits inquiry about current functional ability to perform essential job functions, but prohibits broad disability and medical history inquiries. Asking about current ability to perform clinical privileges is permissible.