CPCS CPCS - Certified Provider Credentialing Specialist Regulatory Requirements and Law Questions and Answers 2

Question 1

Which federal law established the National Practitioner Data Bank and the peer review reporting system?

Accepted Answer

HCQIA (Health Care Quality Improvement Act of 1986)

Answer

HIPAA (Health Insurance Portability and Accountability Act)

Answer

ACA (Affordable Care Act)

Answer

EMTALA (Emergency Medical Treatment and Active Labor Act)

Question 2

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?

Accepted Answer

Civil monetary penalties of up to $20,000 per item or service rendered

Answer

A warning letter for the first offense

Answer

Criminal prosecution only, no civil penalties

Answer

No penalty if the organization was unaware of the exclusion

Question 3

Which federal law requires covered entities to verify, before making payment, that providers are not excluded from participation in federal healthcare programs?

Accepted Answer

Social Security Act, Section 1128 and 1156

Answer

HIPAA

Answer

False Claims Act

Answer

42 CFR Part 1001

Question 4

The anti-kickback statute (42 U.S.C. Section 1320a-7b) has implications for credentialing when:

Accepted Answer

A hospital grants privileges based on referral volume rather than clinical qualifications

Answer

A hospital employs physicians and bills for their professional services

Answer

All employment of credentialed physicians

Answer

Board certification requirements are established for specific privileges

Question 5

Which federal regulation requires hospitals to notify the NPDB within 15 days of accepting a practitioner's voluntary surrender of privileges while under investigation?

Accepted Answer

HCQIA Section 11133

Answer

HIPAA Privacy Rule

Answer

45 CFR Part 60 (NPDB regulations)

Answer

42 CFR Part 482 (Medicare Conditions of Participation)

Question 6

Under the Americans with Disabilities Act (ADA), which inquiry is permissible during the credentialing process?

Accepted 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

Answer

Asking whether the practitioner has been treated for substance abuse in the past 5 years

Answer

Requiring disclosure of all prescription medications the practitioner takes

Answer

Asking for a complete mental health history going back 10 years