Study Session 1/21/2025 Flashcards by Alicia Arterbury

This occurs in a way consistent with any hospital policies or procedures intended to preserve any confidentiality or privilege of information established by applicable law

a. NCQA
b. TJC
c. ACHC

TJC

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CR 7 Element A Factor 1 The administrative policies and procedures indicate that organizations providing managed care services must comply with applicable Federal, State, and local laws and regulations, including requirements for licensure. Thus, the organization’s leaders are responsible for any regulations relating to credentialing

a. NCQA
b. AAAHC
c. TJC

NCQA

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Standards require compliance with applicable law and regulations

a. DNV
b. ACHC
c. NCQA

ACHC

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GB.2 SR.1a Standards require compliance with all applicable federal, state and local laws

a. AAAHC
b. Medicare
c. DNV

DNV

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Standards require compliance with all applicable Federal, State and local laws

a. Medicare & AAAHC
b. URAC & AAAHC
c. DNV & Medicare

URAC & AAAHC

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Interpretive Guidelines §482.12(a)(3) The governing body must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of CoPs

a. DNV
b. ACHC
c. Medicare

Medicare

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HCQIA

Healthcare Quality Improvement Act, 1986

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FACIS

Fraud and Abuse Control Information System

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ECFMG

Educational Commission for Foreign Medical Graduates

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NCCPA

National Commission on Certification of Physician Assistants

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OPPE

Ongoing Professional Practice Evaluation

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ACHC Credentials Committee makes recommendations to the ____ within ____ days of receipt of a completed application.

a. MEC, 60
b. Person taking meeting minutes, 180
c. MEC, 30

MEC, 60

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When is an application truly complete?

a. Once the MSP has reviewed the application.
b. When the applicant signs the Attestation Pages.
c. Once the application itself is complete, all PSV and information required has been obtained.

Once the application itself is complete, all PSV and information required has been obtained

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What is considered a completed application?

a. A completed application is one in which the application itself is not only complete, but all primary source verification and information required by the medical staff bylaws, state and federal law, and accreditation requirements has been obtained.
b. A completed application is one that has been submitted
c. A completed application is one that it has been signed and dated.

A completed application is one in which the application itself is not only complete, but all primary source verification and information required by the medical staff bylaws, state and federal law, and accreditation requirements has been obtained.

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Although not required by accreditation standards, many hospital medical staffs utilize a __________ for evaluation of complete applications, reapplications and grants of privileges.

a. Staff Committee
b. Credentials Committee
c. Executive Committee

Credentials Committee

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ACHC states that recommendations to the Med Exec committee must be made ________days of receipt of a completed application.

a. 45
b. 60
c. 30

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NCQA views the approval decision made by the _______ committee as final decision?

a. Credentials
b. Board
c. MEC

Credentials

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In non-departmentalized hospitals and those with a small medical staff, applications are presented directly to the MEC. The MEC makes its recommendations directly to the board. ________ is the final authority.

a. The medical director
b. The department chair
c. The board

The board

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The Governing Body is the ultimate authority in the hospital organization and is _________ responsibility for everything that happens within the organization.

a. ethically
b. legally
c. clinically

legally

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In non-departmentalized hospitals, complete applications are presented directly to _____.

a. Governing body
b. Credentials Committee
c. MEC

MEC

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One of the things Medicare CoPs state is “if the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or ____________.

a. Education
b. Psychology
c. Osteopathy

Osteopathy

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What is the function of the Governing Body?

a. The Governing Body, or board, is the ultimate authority in the hospital organization and is legally responsible for everything that happens within the organization. Medical staff activities that fall under the board’s responsibility include credentialing and privileging issues (appointments, reappointments, terminations, and granting of clinical privileges), approval of bylaws for the medical staff organizations, oversight of functions delegated to the medical staff organization, and evaluation of the performance of the medical staff. The board must approve the processes for termination of medical staff membership and fair hearing procedures.
b. The Governing Body process appointment and reappointments of medical staff members
c. The Governing Body must meet at least quarterly and as often as necessary to carry out its
responsibilities.

The Governing Body, or board, is the ultimate authority in the hospital organization and is legally responsible for everything that happens within the organization. Medical staff activities that fall under the board’s responsibility include credentialing and privileging issues (appointments, reappointments, terminations, and granting of clinical privileges), approval of bylaws for the medical staff organizations, oversight of functions delegated to the medical staff organization, and evaluation of the performance of the medical staff. The board must approve the processes for termination of medical staff membership and fair hearing procedures.

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What 2 accreditations do not address requirements regarding governing body authority?

a. URAC, NCQA
b. TJC, DNV
c. AAAHC, URAC

URAC, NCQA

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According to URAC, the credentialing committee must have at least one member who what?

a. Has one other role within the specialty department
b. Is accountable for the quality of care provided
c. Does not have any other role in the management of the organization

Does not have any other role in the management of the organization

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Which accreditor considers the date of the Credentialing Committee as the final decision date? a. TJC b. NCQA c. ACHC

NCQA

What standard says that the committee must meet at least quarterly and as often as necessary to carry out its responsibilities. a. NCQA b. DNV c. URAC

URAC

What accrediting body requires the organization to conduct ongoing monitoring that includes the collection and review of complaints? a. TJC b. Medicare c. NCQA

NCQA

The Board must approve the processes for termination of medical staff membership and __________ _________ procedures? a. privilege request b. peer review c. fair hearing

fair hearing

Who must approve the processes for termination of medical staff membership and fair hearing procedures? a. Chief of Staff b. Board / Governing body c. Medical Executive Committee

Board / Governing body

Which accreditation has a formal written grievance procedure? a. URAC b. ACHC c. DNV

DNV

Both the specific complaint and the practitioner’s history of issues must be evaluated. There must be evidence of an evaluation of the history of complaints for all practitioners at least every six months, is stated by which accreditation? a. NCQA b. DNV c. URAC

NCQA

Which standard mentions Interpretive Guidelines when discussing compliance with law? a. DNV b. Medicare c. NCQA

Medicare

What 3 accrediting bodies require compliance with all applicable federal, state and local laws? a. TJC, DNV, Medicare b. ACHC, URAC, AAAHC c. DNV, URAC, AAAHC

DNV, URAC, AAAHC

Who states that the hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance? a. TJC b. URAC c. Medicare

Medicare

Credentialing Committee decisions may be forwarded to a governing body for review, although _________ will still consider the date of the Credentialing Committee as the final decision date. a. URAC b. NCQA c. Medicare

NCQA

Which accreditation holds its leaders responsible to be aware of and comply with local, State, and Federal regulations related to credentialing and privileging of practitioners? a. TJC b. NCQA c. Medicare

TJC

This standard at a minimum must review and send information to the distant-site’s telemedicine entity on all adverse events that result from a physician or practitioner's provisions of telemedicine services, and on all complaints it has received. a. TJC b. Medicare c. ACHC

ACHC

TJC holds the hospitals governing body is _______ to comply with applicable law & regulation while leaders are to be ________. a. Aware / Responsible b. Responsible / Aware c. Responsible / not applicable

Responsible / Aware

This accreditation allows complaints to be part of the recredentialing process through data collected regarding the provider’s performance within the organization? a. AAAHC b. NCQA c. URAC

URAC

Which accreditation does not require verification of education/training if board certification is verified? a. TJC b. NCQA c. URAC

URAC

What accrediting body states the organization must only verify the highest level of credentials attained? a. NCQA b. URAC c. Medicare

NCQA

TJC considers ___________ a primary source for verifying relevant training or experience at the time of appointment. a. The applicant's resume b. The training program c. The applicant's previous employer d. A personal reference

The training program

TJC allows which two sources to be used as DES for verification of Residency / Fellowship? a. ABMS / FCVS b. AMA / AAPA c. AMA / AOA

AMA / AOA

Which standard or standards address compliance with State, Federal and Local Laws? a. TJC b. TJC, NCQA, URAC, AAAHC c. all standards address this

all standards address this

Regarding telemedicine, what accrediting body standards are a direct quotation of the CMS regulations? a. DNV b. ACHC c. AAAHC

ACHC

Which standard states criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges must be included in the bylaws? a. TJC b. DNV c. Medicare

Medicare

In order to provide telemedicine services, one of TJC’s requirements is that the distant site practitioners has a license that is issued or recognized by the state in which? a. The patient is receiving telemedicine services b. The practitioner lives c. The insurance company being paid is located

The patient is receiving telemedicine services

NCQA requires that corrections to incorrect information on an application be corrected by the applicant _______. a. within 15 days of notice b. as outlined in the policy c. no later than 1 week

as outlined in the policy

This standard states that the governing body must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of CoPs? a. AAAHC b. Medicare c. TJC

Medicare

Collected through the quality management program, the collected information regarding the participating provider’s performance is considered as a part of the recredentialing process of ______. a. NCQA b. AAAHC c. URAC

URAC

Which standard states that you must confirm that the state board does verify a credential before relying on the board and time limit for this standard? a. all standards address this; at the time of appointment b. NCQA / URAC; 180 days (MCO) / 120 days (CVO) c. URAC; 180 days of credentialing decision

URAC; 180 days of credentialing decision

What is the distant site? a. Place where the physician or practitioner is providing services b. Place where the patient is c. Place you want to travel too

Place where the physician or practitioner is providing services

With the exception of _____, the standards for the remaining accrediting bodies under “Compliance with Law” state there should be “compliance with all applicable federal, state and local laws.” a. DNV b. NCQA c. ACHC

ACHC

Which 2 accreditations allow you to only verify the highest level of credentials attained when reviewing Residency and Fellowship? a. TJC and Medicare b. NCQA and URAC c. ACHC and AAAHC

NCQA and URAC

The standards for both _____ and ____ state verify highest level of education/training and if the physician is Board certified, verification of the board certification meets the requirement. a. TJC and NCQA b. URAC and DNV c. NCQA and URAC

NCQA and URAC

For telemedicine, ACHC standards are a direct quotation of the _____ regulations? a. NCQA b. DNV c. Medicare

Medicare

There are three accrediting bodies that address Telemedicine, one of the three specifically states the licensed practitioners providing patient care via telemedicine are subject to the credentialing and privileging processes of the originating site. Which one is that? a. TJC b. ACHC c. DNV

TJC

When telemedicine services are furnished to the hospital’s patients through an agreement with a distant-site entity, the governing body of the originating site may choose, in lieu MS 6 to have its medical staff rely upon the decisions made by the distant site entity when recommending privileges. Which standard? a. DNV b. Medicare c. TJC

DNV

Schizophrenia: Splitting of the soul, spirit or mind – a mental disorder

Psychiatrist

Cholecystectomy: a surgical procedure that removes the gallbladder. It's a common treatment for gallstones and other gallbladder issues

General Surgeon Gastrointestinal Surgeon

Tachypnea: a condition of fast, shallow breathing. It is not a disease, but a symptom of another problem, such as a lack of oxygen or too much carbon dioxide in the body

Pulmonology

Otorhinolaryngology: Surgical placement of an electronic device to improve hearing for people who have severe hearing loss from inner-ear damage and do not hear well with hearing aids

Otolaryngology (ENT)