CPCS Flashcards by Eric W

When preparing for a committee meeting, the medical services professional MOST likely would meet with whom to coordinate the agenda and meeting packet?

A) Medical Director
B) Vice President of Medical Affairs
C) Committee chairperson

C) Committee chairperson

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According to The Joint Commission, which of the following dictates the qualifications and criteria for appointment to the medical staff?

A) Credentialing policies and procedures
B) Medical Executive Committee
C) Medical Staff Bylaws

C) Medical Staff Bylaws

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According to URAC, within how many days must the practitioner be notified of credentialing decisions?

A) 10 days
B) 30 days
C) 60 days

A) 10 days

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According to The Joint Commission, which of the following is an approved source for verification of a medical degree from a United States educational Institution?

A) AMA physician masterfile
B) ECFMG
C) ACGME

A) AMA physician masterfile

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How many peer references does HFAP require at initial appointment?

A) One
B) Two

A) One

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According to NCQA standards, an organization that discovers sanction information, complaints, or adverse events regarding a practitioner must take what action?

A) Determine if there is evidence of poor quality that could affect the health and safety of its members
B) Immediately take action to remove the provider from its panel
C) Notify the practictioner that he or she is under investigation and initiate the hiring process

A) Determine if there is evidence of poor quality that could affect the health and safety of its members

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According to The Joint Commission hospital standards, which of the following is an element of a self-governing medical staff?

A) The hospital’s board of directors determines the criteria for granting medical staff privileges
B) There can be any number of medical staffs as long as they are approved by the governing body
C) The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibility to practitioners with independent privileges.

C) The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibility to practitioners with independent privileges.

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In order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with the:

A) Medicare Conditions of Participation
B) National Committee for Quality Assurance (NCQA) standards
C) The Joint Commission of Accreditation of Healthcare Organizations standards

A) Medicare Conditions of Participation

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Robert’s Rules of order is an example of:

A) A code of conduct
B) Executive privilege
C) Parliamentary procedure

C) Parliamentary procedure

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Which of the following providers is considered a primary care physician (PCP)?

A) Family medicine practitioner
B) General surgeon
C) Gastroenterologist

A) Family medicine practitioner

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When credentialing and privileging practitioners, it is appropriate to?

A) Follow a routine process for each applicant
B) Handle each applicant on a case-by-case basis
C) Process all applications within one week of receipt

A) Follow a routine process for each applicant

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Active, Associate, Courtesy, Honorary, and Consulting are examples of:

A) Privileges
B) Membership categories
C) Committees

B) Membership categories

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What is the only hospital medical staff committee required by The Joint Commission hospital standards?

A) Utilization review committee
B) Credentials committee
C) Medical executive committee

C) Medical executive committee

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You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization. If the CVO is not accredited by a nationally recognized organization, you must:

A) Perform an assessment of the capability and quality of the CVO’s work
B) Perform an assessment of their turn-around times.
C) The organization must conduct an onsite survey every three years

A) Perform an assessment of the capability and quality of the CVO’s work

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Can the hospital accept an NPDB self-query performed by the physician to satisfy The Joint Commission’s requirement for NPDB query?

A) Yes
B) No. The hospital or designated agent must perform the query.

B) No. The hospital or designated agent must perform the query.

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Licensure Definition

A) License Independent Practitioner - Term used by TJC
B) A license is the authority a government agency grants an individual to practice
C) Process of obtaining, verifying, & assessing the qualifications of a healthcare practitioner who seeks to provide patient care services for a hospital

B) A license is the authority a government agency grants an individual to practice

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According to TJC Standards temporary privileges may be granted to a Medical staff appointee if the recredentialing application is not submitted in a timely fashion to prevent any lapse.

A) True
B) False

B) False

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HFAP requires a specific document to describe qualifications & criteria for candidates prior to MEC

A) Bylaws or Appended Credentialing Manual
B) Policies and Procedures
C) Rules and Regulations

A) Bylaws or Appended Credentialing Manual

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What document allows a person to give directions about future medical care to designate another person if the individual loses decision making capacity?

A) Power of Attorney
B) Consent Release
C) Advanced Directive

C) Advanced Directive

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NPDB operates by the following laws:

A) Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA), Public Law 99-660 Section 1921 of the Social Security Act, Section 1128E of the Social Security Act

B) Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA)

C) Federal & State Laws

A) Title IV of the Health Care Quality Improvement Act of 1986 (HCQIA), Public Law 99-660 Section 1921 of the Social Security Act, Section 1128E of the Social Security Act

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What is an ex-officio member?

A) service as a member of a body by virtue of an office or position held and, can have voting rights based on hospital bylaws
B) tends to be an established, experienced, and respected, member of the medical staff.
C) A member who recommends approval or disapproval to the board.

A) service as a member of a body by virtue of an office or position held and, can have voting rights based on hospital bylaws

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Office of the Inspector General is the list of individuals organizations that have been excluded from participation in Medicare, Medicaid, and Federal health care programs.

A) True
B) False

A) True

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There may be licensed independent practitioners such as physician assistants or nurse practitioners who are: Allowed by state laws and licensing regulations to practice w/out direction of a physician and may also be granted medical staff membership

A) True
B) False

A) True

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The six areas of “general competencies”: Patient care, medical/clinical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism and systems-based practice were developed by?

A) TJC
B) ACGME and ABMS
C) AMA

B) ACGME and ABMS

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Locum Tenens Definition A) A healthcare practitioner that acts like a proctor B) A healthcare practitioner or individual that fills in for another for a given length of time C) A group of healthcare practitioners

B) A healthcare practitioner or individual that fills in for another for a given length of time

According to JC & HFAP name four approved sources PSV for Medical Education: A) Medical School, AMA, ECFMG, AOA B) Medical School, ECFMG, Sealed Transcript, AMA, AOA C) Medical School, State Agency (if the state agency performs primary source), FCVS, AMA, AOA

A) Medical School, AMA, ECFMG, AOA

T/F Only the highest of training must be verified according to NCQA A) True B) False

A) True

True or false, Can the originating site use the credentialing and privileging decision of the distant-site telemedicine providers? A) True B) False

A) True

Who requires peer references on initial appointment? A) TJC, HFAP, AAAHC, DNV B) HFAP, TJC, NCQA C) URAC, TJC, HFAP

A) TJC, HFAP, AAAHC, DNV

Who reappoints? A) TJC, HFAP, NCQA B) TJC, HFAP, DNV, NCQA, URAC, AAAHC C) TJC, NCQA, URAC, HFAP

B) TJC, HFAP, DNV, NCQA, URAC, AAAHC

Who requires an attestation? A) NCQA, URAC, AAAHC B) TJC, DNV, NCQA C) URAC, DNV, NQCA

A) NCQA, URAC, AAAHC

URAC education verification time limit A) 180 days B) 120 days C) 365 days

A) 180 days

Is a payment made by an insurance company reportable to the NPDB? A) Yes B) No

A) Yes

Who requires that all licensed independent practitoners must be credentialed and privileged through the organized Medical Staff structure? A) TJC B) NCQA C) URAC

A) TJC

Telemedicine originating site is? A) Site where the patient is receiving care is located B) Site where the physician is located

A) Site where the patient is receiving care is located

Which accreditation standards define that the governing body has the ultimate authority and responsibility for oversight and delivery of care rendered by LIPs and other practitioners credentialed and privileged through the medical staff process? A) TJC, HFAP, DNV, AAAHC B) TJC C) TJC, HFAP and AAAHC

A) TJC, HFAP, DNV, AAAHC

CMS recommends that an appraisal be conducted at least every A) 6 months B) 12 months C) 24 months

C) 24 months

Entities must report clinical privileges actions to the NPDB if they result from a professional review action and last longer than A) 15 days B) 30 days C) 60 days

B) 30 days

According to HFAP standards temporary privileges may be granted A) For time of emergency or disaster, Locum tenens, During review and consideration of application,For care of specific patients B) Not specifically addressed C) When is a clean file, and all relevant training or experience have been verified.

A) For time of emergency or disaster, Locum tenens, During review and consideration of application, For care of specific patients

Education verification not required if the practitioner is board certified A) AAAHC B) TJC C) URAC

C) URAC

Which of the following require verification of employment and work history? A) TJC B) HFAP C) DNV-GL D) URAC

B) HFAP

Which of the following require peer recommendations for initial and reappointment? A) AAAHC B) TJC C) NCQA & URAC D) HFAP & DNV-GL

A) AAAHC

Which of the following must verify OIG Medicare/Medicaid exclusions at initial, reappointment and when granting temporary privileges? A) DNV GL B) HFAP C) URAC

A) DNV GL

TJC recommends, but does not require that hospitals based evaluation of experience, ability and current competence on the six areas of General Competencies. A) True B) False

A) True

Per NCQA which of the following is not an acceptable attestation signature? A) The attestation signature may be faxed or scanned B) The attestation signature may be a stamp signature C) The attestation signature may be electronic or digital

B) The attestation signature may be a stamp signature

Which of the following is not a parliamentary procedure? A) Adjourn B) Call Question C) Divide the Table

C) Divide the Table

Per NCQA which of the following is the highest level of training? A) Medical School B) Internship C) Residency D) Fellowship

C) Residency

True or False. URAC verification of education is not required if the practitioner is board certified. A) True B) False

A) True

Per URAC which of the following are not included within the scope of the credentialing standards? A) Non-physicians B) Physicians who are employees of a facility as hospitalists and who are not listed in the provided directory C) Facilities that provide covered health care services to consumers

B) Physicians who are employees of a facility as hospitalists and who are not listed in the provided directory

Which of the following is not included in the AOA Osteopathic Physician Profile Report? A) DEA status B) Osteopathic Specialty Board Certification C) Former name(s) and former addresses (city/state) D) ECFMG status

D) ECFMG status

Which of the following confers deemed status? A) AOA B) TJC C) CMS D) HCQIA

C) CMS

According to NCQA what is the verification time limit for the attestation? A) 365 days B) 120 days C) 180 days

A) 365 days

According to NCQA which of the following documents must be verified through the direct source? A) Professional Liability Insurance B) License C) DEA

B) License

According to NCQA a practitioner must provide documentation of work history for a minimum of how many years? A) 3 B) 5 C) 7

B) 5

NIAHO Standards are a direct quotation of the? A) CMS regulations B) Medical Staff Rules & Regulations C) Medical Staff Bylaws D) HFAP Standards

A) CMS regulations

True or False. According to TJC new requests for privileges (those not occurring together with appointment) are typically processed in the same manner as the initial grant of privileges. A) True B) False

A) True

According to TJC, the organization may delegate appointment decisions to which of the following? A) A committee of two members of the Governing Body B) Medical Executive Committee C) Credentials Committee of the medical staff

A) A committee of two members of the Governing Body

TJC requires the medical staff to review which information prior to recommending privileges? A) Board certification status B) Relevant practitioner specific data C) Open malpractice claims

B) Relevant practitioner specific data

According to the Joint Commission, who is responsible for developing criteria for FPPE when issues affecting the provision of safe patient care are identified? A) Medical Staff B) Governing Body C) Department Chair

A) Medical Staff

Peritoneal dialysis is treatment ordered by which of the following practitioners? A) Nephrologist B) Oncologist C) Hematologist

A) Nephrologist

How frequently does CMS recommend that an appraisal of each member of the medical staff be conducted? A) At least every 24 months following initial appointment B) At least every 6 months following initial appointment C) Annually following initial appointment and every two years thereafter

A) At least every 24 months following initial appointment

According to NCQA, at recredentialing, which of the following must be verified within 180 days prior to the credentialing decision? A) Lifetime board certification B) Hospital Affiliation C) Privileges

A) Lifetime board certification

According to URAC, how often must a periodic review of delegated functions occur? A) No less than every two years B) No less than every three years C) No less than annually

B) No less than every three years

In what document does CMS require a description of privileging criteria and the procedures for applying the criteria? A) Rules and Regulations B) Credentialing Policies C) Medical Staff Bylaws

C) Medical Staff Bylaws

Which legislation prohibits a physician with a financial arrangement with an entity from referring Medicare / Medicaid patients to that entity? A) Stark Law B) HCQIA C) EMTALA

A) Stark Law

NCQA requires an organization to have which of the following? A) Department-specific procedures B) Credentialing Policies and Procedures C) Governing Board Bylaws

B) Credentialing Policies and Procedures

According to TJC, the credentialing decision is communicated to the practitioner within what timeframe? A) 15 days B) 30 days C) As specified in the medical staff bylaws

C) As specified in the medical staff bylaws

According to NCQA, an initial application must include which of the following verifications? A) All active licenses B) Hospital Affiliations C) Five years of pending malpractice claims history

C) Five years of pending malpractice claims history

According to TJC, the AMA is considered an equivalent primary source for which of the following? A) Licensure actions B) Medical school graduation C) Medicare/Medicaid sanctions

B) Medical school graduation

According to NCQA, when must specific practitioner site visits be conducted? A) When a complaint is filed B) At the time of recredentialing C) Prior to the initial credentialing decision

A) When a complaint is filed

NCQA requires an organization to obtain a claims history for a minimum of how many years? A) 5 B) 3 C) 10

A) 5

True or False. Per TJC all licensed independent practitioners and other practitioners privileged through the medical staff process must participate in continuing education. A) True B) False

A) True

Which of the following specifically delineates the required components of a fair hearing process? A) HCQIA B) CMS C) NCQA

A) HCQIA

According to TJC, which individual can provide a peer reference for a physician assistant? A) Physician Assistant B) Doctor of Medicine C) Nurse Practitioner

A) Physician Assistant

Which of the following would be considered confidential credentialing information? A) Birth Date B) License Expiration Date C) Board certification date

A) Birth Date

Are limitations of the clinical privileges of a psychiatrist for more than 30 days reportable to the NPDB?

YES

According to the Joint Commission, who may amend the medical staff bylaws?

Medical Staff

Failure to meet the established qualifications and criteria for appointment should be reported to whom?

The applicant

NCQA requires the MCO to obtain a minimum of _____years of work history?

Five years

According to NCQA what policy must an organization have in place to obtain approval to enter into a delegated agreement?

Credentialing policies

How often does the OIG report to the NPDB?

Monthly

Hospitals must query the NPDB when:

Initial appt, granting of privileges, every two years

NCQA requires verifications be less than how many days old?

180 days

What is the verification time limit on malpractice history according to the NCQA?

180 days

Time limited credential must be verified by the CVO within how many days prior to submission to the client?

120 days

According to AAAHC, for initial appointments, in addition to licensure and education, what verification is required ?

Experience and hospital affiliation

What accreditation body states “the NPDB is an acceptable source for sanctions or limitations on licensure, Medicaid/Medicare sanctions and malpractice history”?

NCQA

Who is required to query the NPDB?

Hospitals

Is disciplinary action taken against the license of a dentist reportable to the NPDB?

Yes

Under HCQIA, a hospital failure to report an adverse privilege action lasting longer than 30 days may cause the organization to lose HCQIA immunity for how many years?

3 years

According to NCQA verification of Medicare/Medicaid sanctions can be queried by any of what sources?

AMA, FSMB, HIPDB, OIG, Sanctions Report, NPDB, State Agency

According to NCQA, how often must an organization conduct an audit of the credentialing process delegated to another organization?

Annually

How far back does the Joint Commission require evaluation of malpractice history? What source may be used?

Back to medical school NPDB

Is an internet verification from a website not contracted by the primary source that attests to the accuracy and timeliness of the information considered a complete verification by NCQA?

What accreditation bodies require privileges to be distributed to essential department personnel?

Joint Commission/CMS

T/F the Joint Commission does not require criminal background checks.

True (unless employed, then HR must perform background check)

Is a payment made by an insurance company reportable to the NPDB?

Yes

Who is the best person to consult when releasing adverse information in a verification request form another organization?

Legal Counsel

According to CMS, who in the organization may make decisions regarding approval of credentialing applications?

Governing board

What are the six elements of a written delegation agreement?

1. Mutually agreed upon 2. Describes responsibilities of organization and delegated entity 3. Describes delegated activities 4. Requires semi-annual reporting to the organization 5. Describes the process by which the organization evaluates the delegated entities performance 6. Describes remedies available to the organization if the delegated entity does not fulfill its obligations including revocation of delegated agreement

According to NCQA what providers are NOT required to be credentialed when working in an independent relationship?

Locums Tenens Hospital based practitioners (i.e. Anesthesia, Pathology, Radiology, etc.)

How many peer references does HFAP require at initial appointment?

T/F Denial of a medical license application by a state medical board is not reportable to the NPDB?

True

What accreditors state: a hospital may not rely solely on board certification when considering practitioner for medical staff membership?

HFAP, CMS

According to the Joint Commission & HFAP name four approved sources for PSV for medical education?

Medical School, AMA, ECFMG, AOA

According to NCQA practitioners must be notified of credentialing decision within how many days?

60 days

The DHHS mails a copy of the NPDB report to the named provider. If the provider wishes to dispute the reports accuracy, the provider has how many days to do so?

60 days

According to URAC, within how many days must the practitioner be notified of credentialing decisions?

How many days does a practitioner have to dispute an NPDB report accuracy?

Which accrediting body requires five year verification of malpractice history?

NCQA

What is the commonly used source for verifying malpractice history?

NPDB

According to the Joint Commission a fair hearing and appeals process as described in the medical staff bylaws is available to whom?

Medical staff members and non-members holding clinical privileges

T/F only the highest level of training must be verified according to the NCQA.

True (does not include fellowship)

According to the Joint Commission a peer recommendation should address what six competencies?

``` Medical knowledge technical and clinical skills clinical judgment interpersonal skills communications skills professionalism ```

Telemedicine – according to TJC what three options are available for credentialing at the originating site?

Full credentialing, use of the distant sites credentialing information, use of decision from distant site

According to TJC what is included in the process of planning and implementing privileges?

1. Developing and approving a procedure list 2. Processing the application 3. Evaluate applicant specific information 4. Submit recommendations to the governing body for applicant specific delineated privileges 5. Notify the applicant, relevant personnel 6. Monitor the use of privileges

Are payments made by a physician in a malpractice claim reportable to the NPDB?

A hospital that does not query the databank as required by HCQIA is:

Legally liable for knowledge of any information reported

According to TJC, OPPE should be performed on whom?

All privileged practitioners

According to TJC who can provide confirmation of an applicant’s health status

Director of post graduate training program, chief of services or chief of staff of another hospital where applicant holds privileges, peer reference

According to NCQA any gap in personal history greater than ____must be clarified in writing.

One year

According to TJC what two verifications must be performed before granting of privileges to satisfy an important patient care need?

Current licensure, current competence

According to TJC what committee is required to review and make recommendations regarding credentialing applications?

MEC

What document is best used to evaluate if an applicant meets an organizations minimum credentialing criteria?

Pre-application

Name an essential source when developing a peer review policy?

HCQIA

According to NCQA what requires ongoing monitoring between credentialing cycles?

License sanctions

The HCQIA was passed into law in what year?

1986

According to URAC the credentialing application must include what?

Release of information

What is the NCQA’s requirement for history of felonies on applications and reappointment?

The application requires a statement from the applicant

According to the TJC what is required to be verified at the time of expiration?

License

According to NCQA standards, if deficiencies are noted during a site visit an action plan must be developed. The office site must implement the plan within how many months of the initial visit?

Six months

If the physician is notified of an adverse recommendation and requests a hearing what is required in the notice?

1. Place, time and date 2. Hearing date within 30 days from date of notice 3. List of witnesses

What is the time limit on PSV of current licensure according to NCQA? 180 days

180 days

When an applicant for membership or privileges with a clean application is awaiting approval of MEC and the governing body, temporary privileges may be granted for a limited time not to exceed how many days? 120 days

120 days

Name two sources of verification of education of a chiropractor according to NCQA?

Chiropractic college, State licensing agency

T/F the TJC requires PSV of board certification.

False

According to URAC what must be verified using primary source?

State licensure, highest level of education

According to TJC who has the ultimate authority in credentialing decisions?

Governing body

According to NCQA, a provisional period is granted for no longer than ____days?

According to NCQA what verification is required before provisional credentialing is permitted?

Current license, 5 year malpractice history

NCQA requires an attestation of good health and competence to perform essential functions. How is this achieved?

Signed attestation

Within how many days must a medical malpractice payor report payment resulting from written claim or judgment to the NPDB & state licensing board?

30 days

According to TJC, appointment or reappointment to the medical staff and granting, renewal or revision of clinical privileges are made for a period of no more than?

Two years

What is the verification time limit for verification of Medicare/Medicaid sanctions according to NCQA?

180 days

What came first? HIPDB or NPDB

NPDB

According to NCQA, how long is the signature on the attestation good for? How long for CVO’s?

365 305

How often does AAAHC require recredentialing?

At least every 3 years

According to URAC who should oversee the clinical aspects of the credentialing program within the organization?

Senior clinical staff person

Name 3 sources of verification of education of a dentist according to NCQA?

Dental school, specialty board, state licensing board

NCQA requires MCO’s to recredential practitioners at least every ______

3 years

HFAP is commonly known as

AOA, an osteopathic organization

What six criteria are observed in an initial site visit by NCQA?

1. Physical accessibility 2. Physical appearance 3. Adequacy of waiting and exam rooms 4. Appointment availability 5. Adequacy of treatment 6. Record keeping processes

According to TJC which of the following should be used to verify current competence? Board certification or hospital verification

Hospital verification

According to NCQA, who has ultimate authority in credentialing decisions?

Credentials committee or medical director if it is a clean file

What two entities does EMTALA not apply?

Military and Shriners

Name the six general competencies according to the ACGME and ABMS?

1) Patient care 2) Medical/clinical knowledge 3) Practice based learning and improvement 4) Interpersonal and communication skills 5) Professionalism 6) System based practice

If a physician is not board certified, completion of residency can be completed through which entities:

1) Residency Training Prog 2) AMA 3) AOA 4) Assoc of schools of the health profession 5) State licensing agency 6) FCVS if closed residency

According to NCQA application PSV must be dated within____days of the credentialing decision?

180 days

According to NCQA what credential must be verified at the time of recredentialing?

Current malpractice and state license

According to the TJC when must a license be verified?

Appointment, reappointment, granting of privileges and expiration

NCQA requires PSV of board certification. What sources can be used? How long is the verification good for?

1) ABMS, AOA, AMA, specialty board, state licensing board | 2) 180 days

What are some sources that can be used to determine which procedures should be performed by which specialty?

Specialty Board, White papers,

The following agencies must report adverse actions or payouts within how many days?

1) Malpractice payors - 30 days 2) State licensing board – 30 days 3) Hospitals and other health care entities – 15 days 4) Professional societies – 15 days

Name 3 sources of verification of education of a podiatrist according to NCQA?

School, specialty board, state licensing board

Adverse actions affecting clinical privileges for a period longer than _____days must be reported to the NPDB. Report should be submitted immediately to the state and NPDB within ____days of the action.

30, 30

Within how many days of a licensure disciplinary action, based on reasons related to professional conduct, must the licensing board report to the NPDB?

An organization has sent a request for information regarding a physician on staff who has exhibited behaviorial issues at a facilty. What release form should be facility obtain prior to releasing this information to the requesting organization?

Special release developed by the MEC

According to NCQA if a practitioner terminates or is terminated from the contract or there is a break in service over 30 days, can the practitioner be reinstated without credentialing?

The organization must initially credential the practitioner before reinstatement

Name the five schedules of the DEA registration.

1) I – HIGH ABUSE POTENTIAL – NO MEDICAL USE 2) II – HIGH ABUSE POTENTIAL WITH DEPENDANCE LIABILITY 3) III – LESS ABUSE POTENTIAL,MODERATE DEPENDENCE 4) IV – LESS ABUSE POTENTIAL, LIMITED DEPENDENCE 5) V – LIMITED ABUSE POTENTIAL

Which agency requires a Medicare attestation?

CMS

According to TJC rules on credentialing of telemedicine providers, the originating site can use credentialing and privileging information from the distant site if what three requirements are met?

1) Distant site is TJC accredited 2) The provider is privileged at the distant site 3) The originating site has evidence of an internal review

Individuals providing information to professional review bodies regarding the competence or conduct of a physician are protected from liability except?

When the information provided is false and the person providing the information knew it was false

When preparing for a committee meeting, who would an MSP most likely meet with to coordinate the agenda and meeting packet?

Committee Chairperson

TJC - Medical record review is performed how often?

Quarterly (every 3 months)