CPCS 2018 Practice Exam
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Questions and Answers

If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?

  • Director of Medical Records
  • Chief of Staff
  • Organization's attorney (correct)

    • Prior to releasing information to a third party regarding a practitioner, the organization should acquire:

  • Approval from the organization's attorney
  • A signed consent and release form (correct)
  • A picture ID of the provider

    • If the CVO is not accredited by a nationally recognized organization, you must:

  • Perform an assessment of their turn-around times.
  • Perform an assessment of the capability and quality of the CVO's work
  • Perform an initial on-site visit of the CVO to assess their capabilities and quality of work. (correct)

    • What is the verification time limit for licensure per NCQA CVO standards?

    <p>120 days</p> Signup and view all the answers

    According to The Joint Commission standards, initial appointments to the medical staff are not to exceed what time period?

    <p>Not to exceed 1 year to the day</p> Signup and view all the answers

    At what times must the applicant's participation in continuing education be evaluated according to The Joint Commission standards?

    <p>Reappointment and requesting new privileges</p> Signup and view all the answers

    According to NCQA standards, on initial application, the review of information on sanctions, restrictions on licensure and limitations on scope of practice must cover what time period?

    <p>Most recent 5 years</p> Signup and view all the answers

    At what times must the hospital query the NPDB for a physician, dentist, or other health care practitioner according to HCQIA?

    <p>When applying for a position on its medical staff or for clinical privileges; and every 2 years after that</p> Signup and view all the answers

    What medical staff committee(s) are required by The Joint Commission hospital standards for the medical staff?

    <p>Board, MEC, and Credentials Committee</p> Signup and view all the answers

    The Joint Commission standards specifically require verification of medical malpractice insurance.

    <p>False</p> Signup and view all the answers

    At initial credentialing, URAC standards require primary source verification of what two elements?

    <p>Board certification (or highest level of education) and state licensure</p> Signup and view all the answers

    Which specialty is most likely to be granted privileges for surgical management of congenital septal and valvular defects?

    <p>Cardiovascular or cardiothoracic surgeon</p> Signup and view all the answers

    URAC standards require the organization to provide a written notification to providers within how many business days of the credentialing determination?

    <p>10 days</p> Signup and view all the answers

    According to NCQA standards, practitioners must be notified of their rights. Which of the following rights must they be notified of?

    <p>All of the above</p> Signup and view all the answers

    When recredentialing, NCQA requires the organization to verify five factors. Which of the following is NOT one of them?

    <p>Continuing medical education credits</p> Signup and view all the answers

    According to NCQA, the ABMS Certified Doctor Verification Program, accessible through the ABMS website, is an acceptable source for verifying board certification of an MD.

    <p>False</p> Signup and view all the answers

    The Joint Commission requires licensure to be verified with the primary source at what times?

    <p>All of the above</p> Signup and view all the answers

    According to The Joint Commission, the hospital must query the NPDB at what times?

    <p>All of the above</p> Signup and view all the answers

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

    <p>False</p> Signup and view all the answers

    According to NCQA standards, an organization must verify sanctions or limitations on licensure in each state where the practitioner holds or has ever held licensure.

    <p>False</p> Signup and view all the answers

    When verifying licensure sanctions for physicians, NCQA allows verification with NPDB, HIPDB, the appropriate state agency(ies), and what other organization?

    <p>FSMB (The Federation of State Medical Boards)</p> Signup and view all the answers

    According to NCQA standards, is verification from the ECFMG acceptable for education and training completed through the AMA's Fifth Pathway program?

    <p>False</p> Signup and view all the answers

    According to AAAHC standards, can information from another healthcare organization that has performed PSV be accepted for credentialing?

    <p>True</p> Signup and view all the answers

    According to The Joint Commission standards, peer recommendation must include written information regarding six elements. Which of the following is NOT one of the required elements?

    <p>Research publication history</p> Signup and view all the answers

    What are the four appropriate sources of peer recommendations according to The Joint Commission standards?

    <p>All of the above</p> Signup and view all the answers

    Per NCQA, is there any situation in which it would be acceptable to use confirmation from the state licensing agency in lieu of verification of education?

    <p>True</p> Signup and view all the answers

    According to URAC's health network standards, must licensure information from all states be included or only those in which the applicant will be providing services?

    <p>All states where the applicant has licensure</p> Signup and view all the answers

    Which of the following credentials must be tracked on an ongoing basis and why?

    <p>State licensure</p> Signup and view all the answers

    For written verification received by the organization, does NCQA use the date the organization stamps the document as 'received' as the date of the official document?

    <p>False</p> Signup and view all the answers

    For internet and electronic verification, if the source report does not generate a date, what date does NCQA use as the verification date?

    <p>The date noted in the credentialing file by the organization staff person</p> Signup and view all the answers

    The Joint Commission requires an initial application to be completed in 120 days.

    <p>False</p> Signup and view all the answers

    NCQA sets a 120-day time limit for verification of licensure by a CVO.

    <p>True</p> Signup and view all the answers

    According to TJC, all LIPs, APRNs, and PAs must be credentialed through the medical staff process.

    <p>True</p> Signup and view all the answers

    NCQA allows the use of signature stamps on an application.

    <p>False</p> Signup and view all the answers

    A consent and release on an application allows an organization to obtain additional peer references than those provided by the applicant.

    <p>True</p> Signup and view all the answers

    When granting temporary hospital privileges, what minimum information do you need to verify?

    <p>All of the above</p> Signup and view all the answers

    Under what circumstances does NCQA allow exceptions to the 36-month recredentialing timeframe?

    <p>All of the above</p> Signup and view all the answers

    Why is it important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal health care programs?

    <p>A facility could lose its accreditation if it does not do so</p> Signup and view all the answers

    Which of the following credentials must be tracked on an ongoing basis?

    <p>Licensure</p> Signup and view all the answers

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

    <p>Determine if there is evidence of poor quality that could affect the health and safety of its members.</p> Signup and view all the answers

    What is the name of the entity established through the Health Care Quality Improvement Act of 1986?

    <p>The National Practitioner Data Bank</p> Signup and view all the answers

    When developing clinical privileging criteria, which of the following is important to evaluate?

    <p>Established standards of practice, such as specialty board recommendations</p> Signup and view all the answers

    What is the main reason for periodically assessing appropriateness of clinical privileges of each specialty?

    <p>To protect patient safety by ensuring current competency, relevance to the facility, and accepted standards of care.</p> Signup and view all the answers

    Which of the following specialists is most likely to perform a PTCA?

    <p>Interventional Cardiologist</p> Signup and view all the answers

    The Joint Commission hospital standards require that clinical privileges are hospital specific and...

    <p>Based on the individual's demonstrated current competence and the procedures the hospital can support</p> Signup and view all the answers

    Which of the following would be routinely performed by a cardiologist?

    <p>Transesophageal Echocardiography</p> Signup and view all the answers

    Which NCQA-required committee makes recommendations regarding credentialing decisions?

    <p>Credentialing Committee</p> Signup and view all the answers

    HFAP standards require which three medical staff committees to be delineated in the medical staff structure?

    <p>Utilization Review Committee</p> Signup and view all the answers

    How often does NCQA require that delegation reports be evaluated by the health plan?

    <p>Semi-Annually</p> Signup and view all the answers

    Peer references should be obtained from:

    <p>Practitioners in the same professional discipline as the applicant</p> Signup and view all the answers

    NCQA recognizes which of the following as the final approval of an applicant who does not meet criteria for a clean file?

    <p>Medical Director</p> Signup and view all the answers

    If a medical staff member has privileges and/or medical staff appointment revoked, he/she must be:

    <p>Provided due process</p> Signup and view all the answers

    Access to credentials files should be:

    <p>Described fully in an access policy</p> Signup and view all the answers

    Which of the following bodies approves clinical privileges?

    <p>Medical Executive Committee</p> Signup and view all the answers

    What primary source verification is required by NCQA prior to provisional credentialing?

    <p>Licensure and 5-year malpractice history or NPDB</p> Signup and view all the answers

    According to The Joint Commission standards, initial appointments to the medical staff are made for a period of:

    <p>A reasonable time as determined by the medical staff bylaws not to exceed two years</p> Signup and view all the answers

    According to The Joint Commission standards, temporary privileges may be granted by:

    <p>The CEO on the recommendation of the medical staff president or authorized designee</p> Signup and view all the answers

    According to The Joint Commission standards, which of the following items must be verified with a primary source?

    <p>Licensure, training, experience, and competence</p> Signup and view all the answers

    According to NCQA standards, a copy of which of the following is acceptable verification of the document?

    <p>Licensure</p> Signup and view all the answers

    According to NCQA standards, which is an acceptable source for primary source verification of Medicare and Medicaid sanction activity against physicians?

    <p>Federation of State Medical Boards (FSMB)</p> Signup and view all the answers

    According to The Joint Commission standards, which of the following is considered a designated equivalent source for verification of board certification?

    <p>American Board of Medical Specialties (ABMS)</p> Signup and view all the answers

    Which of the following organizations have been recognized by The Joint Commission and NCQA to provide primary source verification of medical school graduation and residency training for U.S. graduates?

    <p>American Medical Association Masterfile</p> Signup and view all the answers

    According to NCQA standards, the application attestation statement must affirm that the application:

    <p>Is correct and complete</p> Signup and view all the answers

    According to The Joint Commission standards, medical staff bylaws should define:

    <p>The structure of the medical staff</p> Signup and view all the answers

    According to The Joint Commission hospital standards, professional criteria for granting clinical privileges must include at least:

    <p>Relevant training and experience, ability to perform privileges requested, current licensure, and competence</p> Signup and view all the answers

    The Joint Commission hospital standards require medical staff bylaws to include:

    <p>A mechanism for selection and removal of officers</p> Signup and view all the answers

    According to NCQA standards, which of the following is an approved source for verification of board certification?

    <p>State licensing agency if state agency conducts primary verification of board status</p> Signup and view all the answers

    According to The Joint Commission hospital standards, which of the following is a required component of the reappointment process?

    <p>Medicare/Medicaid sanctions query</p> Signup and view all the answers

    According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following:

    <p>State licensure information, including current license(s) and history of licensure in all jurisdictions</p> Signup and view all the answers

    According to AAAHC, which must be monitored on an ongoing basis?

    <p>Current licensure</p> Signup and view all the answers

    According to The Joint Commission, a nurse practitioner functioning independently and providing a medical level of care must:

    <p>Be granted delineated clinical privileges</p> Signup and view all the answers

    According to The Joint Commission, which of the following is an acceptable source for verification for medical education of an international graduate?

    <p>Education Commission for Foreign Medical Graduates</p> Signup and view all the answers

    When evaluating compliance with the required time-frame for recredentialing, NCQA counts the recredentialing period to the:

    <p>Year</p> Signup and view all the answers

    NCQA standards require the organization to verify board certification at recredentialing:

    <p>In all cases</p> Signup and view all the answers

    To whom does the AAAHC give the responsibility for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management?

    <p>Medical director</p> Signup and view all the answers

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

    <p>Medicare Conditions of Participation</p> Signup and view all the answers

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

    <p>The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibility to practitioners with independent privileges</p> Signup and view all the answers

    Robert's Rules of order is an example of:

    <p>Parliamentary procedure</p> Signup and view all the answers

    The medical staff application should provide a chronological history of:

    <p>The applicant's education, training and work history</p> Signup and view all the answers

    In order to participate in a health plan, a provider must be accepted to the plan's:

    <p>Provider panel</p> Signup and view all the answers

    In order for a physician to practice medicine in any state in the United States, he/she must possess:

    <p>Current state licensure</p> Signup and view all the answers

    Which of the following is considered post-graduate education?

    <p>Residency training</p> Signup and view all the answers

    Which of the following elements may not be used to evaluate credentials of applicants?

    <p>Gender</p> Signup and view all the answers

    The release of liability statement signed by the applicant for medical staff appointment should include:

    <p>A statement providing immunity to those who respond in good faith to requests for information</p> Signup and view all the answers

    Primary source verification is:

    <p>Receiving information directly from the issuing source</p> Signup and view all the answers

    Unexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of:

    <p>Red flags</p> Signup and view all the answers

    When documenting a telephone conversation regarding primary source verification what should be documented?

    <p>Name of the person and organization contacted, date of call, what was discussed and who conducted the interview</p> Signup and view all the answers

    According to HFAP standards, when confirming malpractice coverage the organization must:

    <p>Have evidence of professional liability insurance, which includes certificate showing amounts of coverage</p> Signup and view all the answers

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

    <p>Family medicine practitioner</p> Signup and view all the answers

    Which body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges?

    <p>Governing Body</p> Signup and view all the answers

    When credentialing and privileging practitioners, it is appropriate to:

    <p>Handle each applicant on a case-by-case basis</p> Signup and view all the answers

    Medical liability insurance should be held in what limits?

    <p>As specified by the medical staff and board of directors</p> Signup and view all the answers

    Which of the following would be an appropriate question to ask an applicant for medical staff?

    <p>Do you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting?</p> Signup and view all the answers

    The governing body delegates the responsibility of credentialing, recredentialing, and privileging to:

    <p>The medical staff</p> Signup and view all the answers

    Who should have access to medical staff meeting minutes?

    <p>Personnel as documented in a records access policy and procedure</p> Signup and view all the answers

    In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes?

    <p>Names and professional titles of all in attendance</p> Signup and view all the answers

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

    <p>Membership categories</p> Signup and view all the answers

    Changes in medical staff bylaws are not final until formally approved by the:

    <p>Governing body</p> Signup and view all the answers

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

    <p>Credentials committee</p> Signup and view all the answers

    The Healthcare Quality Improvement Act:

    <p>Provides qualified immunity from antitrust liability arising out of peer review activities that are conducted in good faith</p> Signup and view all the answers

    Study Notes

    Practitioner Exclusions & Federal Programs

    • Checking practitioner eligibility is crucial to avoid facility accreditation loss.
    • Required by Medicare Conditions of Participation for reimbursement of services.

    Ongoing Credentialing Requirements

    • Licensure, postgraduate education, and malpractice claims must be tracked continuously.

    NCQA Standards & Practitioner Issues

    • Organizations must investigate and act on sanctions or complaints regarding practitioners.
    • Immediate action may include removing providers from panels or notifying them of investigations.

    National Practitioner Data Bank

    • Established under the Health Care Quality Improvement Act of 1986 to disclose malpractice and adverse action histories.

    Clinical Privileging Criteria

    • Evaluate standards of practice, such as specialty board recommendations and the number of providers within a specialty.

    Periodic Assessment of Clinical Privileges

    • Required for maintaining patient safety, ensuring practitioner competency, and adherence to care standards.

    PTCA Specialists

    • Interventional Cardiologists are the primary specialists performing Percutaneous Transluminal Coronary Angioplasty (PTCA).

    Joint Commission Standards on Clinical Privileges

    • Clinical privileges must be specific to the hospital and based on a practitioner's demonstrated competence.

    Cardiology Procedures

    • Cardiologists routinely conduct Transesophageal Echocardiography, not hysterectomies or urethral dilations.

    NCQA Credentialing Committees

    • The Medical Executive Committee, Quality Care Committee, and Credentialing Committee participate in credentialing recommendations.

    HFAP Medical Staff Committees

    • Must include a Medical Executive Committee, a Utilization Review Committee, and a Credentials Committee.

    Health Plan Delegation Reports

    • Evaluations must be conducted semi-annually as per NCQA requirements.

    Peer References

    • Should be obtained from practitioners in the same specialty or those who have referred to the applicant.

    Final Approval for NCQA Applications

    • The Credentialing Committee or Medical Director decides on applicants lacking clean files.

    Due Process in Revocation of Privileges

    • Medical staff members with revoked privileges must receive due process and be reported to the National Practitioner Data Bank.

    Access to Credentialing Files

    • Credential files access policies must be clearly described, with specific availability restrictions.

    Approval of Clinical Privileges

    • Clinical privileges are approved by the Credentials Committee, Medical Executive Committee, and Governing Body.

    Primary Source Verification by NCQA

    • Requires verification of licensure, malpractice history, and ability to perform requested privileges.

    Joint Commission Initial Appointment Duration

    • Appointments last a period determined by bylaws, not exceeding two years.

    Granting of Temporary Privileges

    • Temporary privileges can be granted by the CEO or authorized designee based on medical staff recommendations.

    Primary Source Verification Items

    • Must verify licensure, training, experience, competence, and sanctions related to Medicare/Medicaid.

    Acceptable Verification Sources

    • NCQA recognizes certain organizations like FSMB for primary verification of sanctions.

    Joint Commission Designated Source for Board Certification

    • The American Board of Medical Specialties (ABMS) is an acceptable source for board certification verification.

    Medical School and Residency Training Verification

    • Organizations like the American Medical Association Masterfile and FSMB are recognized for confirming graduate credentials.

    Application Attestation Statement

    • Must confirm that the application was completed by the provider and is accurate.

    Medical Staff Bylaws Determination

    • Bylaws must outline appointment mechanisms, staff structure, and emergency call scheduling.

    Professional Criteria for Privileges

    • Must include training, experience, licensure, competence, and verification of prior malpractice claims.

    Medical Staff Bylaws Inclusion

    • Bylaws must define review processes for quality of care and removal of executive staff.

    Verification of Board Certification

    • Conducted for all practitioners during recredentialing as per NCQA standards.

    Reappointment Process Components

    • Must include health status documentation and Medicare/Medicaid sanctions query.

    URAC Health Network Standards

    • Applications must include state licensure and a comprehensive list of hospital affiliations.

    Ongoing Monitoring Requirements

    • NCQA standards necessitate monitoring current licensure and malpractice coverage.

    Nurse Practitioners and Medical Privileges

    • Independent nurse practitioners must possess clinical privileges and have job descriptions.

    Education Verification for International Graduates

    • Education credentials must be verified through the Education Commission for Foreign Medical Graduates.

    NCQA Recredentialing Timeframes

    • Counts recredentialing periods to the year, not the month or week.

    Credentialing Responsibility

    • The governing body delegates credentialing and privileging to the medical staff.

    Accessing Medical Staff Meeting Minutes

    • Access should align with documented policies and may include governing body members.

    Documentation in Meeting Minutes

    • Must include names, titles of attendees, date of the next meeting, and any necessary follow-ups.

    Classification of Medical Staff Membership

    • Examples include Active, Associate, and Consulting membership categories.

    Changes in Medical Staff Bylaws

    • Require approval from the governing body to be finalized.

    Joint Commission Required Committee

    • Only the Credentials Committee is mandated as per hospital standards.

    Quality Improvement Act Liability Protections

    • Provides immunity for good faith peer review activities to prevent lawsuits.

    Release of Practitioner Information

    • Requires a signed consent and release form before third-party disclosure.

    CVO Accreditation Assessment

    • Non-accredited CVOs necessitate initial on-site evaluations for their quality and capabilities.

    Verification Time Limit for Licensure

    • Set to a maximum of 180 days per NCQA CVO standards.

    Initial Staff Appointments Duration Maximum

    • Set by The Joint Commission standards at not exceeding three years.

    Continuing Education Evaluation for Reappointment

    • Assessed during the initial appointment and reappointment phases.

    Sanction Review Period

    • NCQA mandates review for sanctions covering the most recent five years upon initial applications.### HCQIA Query Requirements
    • Hospitals must query the National Practitioner Data Bank (NPDB) at the initial granting of privileges, renewal of privileges, and when a new privilege is requested.
    • A practitioner’s application for new privileges also triggers the need for an NPDB query.

    Joint Commission Standards

    • Required medical staff committees: Board, Medical Executive Committee (MEC), and Credentials Committee.
    • The Joint Commission does not require verification of medical malpractice insurance.

    URAC Standards for Initial Credentialing

    • URAC mandates primary source verification of board certification (or highest level of education) and state licensure during initial credentialing.
    • Providers must be notified in writing within 10 business days of credentialing determinations.

    NCQA Standards for Practitioner's Rights

    • Practitioners must be informed of their rights to review submitted information, correct erroneous information, inquire about the status of their application, and receive notification of these rights.

    Recredentialing Verification

    • NCQA requires verification of licensure, board certification (if applicable), history of malpractice claims, and licensure sanctions for the past five years during recredentialing.
    • Verification from the ABMS Certified Doctor Verification Program is not considered primary source verification.

    Peer Recommendations

    • Peer recommendations must address professionalism, medical knowledge, technical skills, clinical judgment, interpersonal skills, and communication skills.
    • Acceptable sources for peer recommendations include organized performance improvement committees and reference letters from knowledgeable peers.

    Acceptable Verification Methods

    • Confirmation from the state licensing agency may substitute for verification of education and residency if the agency conducts primary source verification.
    • Ongoing tracking of state licensure is essential, as licensure can expire, unlike other static credentials.

    NCQA Standards on Document Dates

    • The date on the official document is used to assess timeliness, rather than the date the organization receives it.
    • For electronic verification, if a source report does not generate a date, NCQA uses the date noted by organizational staff during verification.

    Credentialing Process and Time Limits

    • Initial applications are not bound to a 120-day limit set by The Joint Commission; the hospital determines its own processing time.
    • NCQA stipulates a 120-day time limit for verification of licensure by a Credentialing Verification Organization (CVO).

    Temporary Privileges and Exceptions

    • Minimum verification for temporary hospital privileges includes current licensure, NPDB query, professional liability insurance, and clinical competence verification.
    • Exceptions to the standard 36-month recredentialing timeframe can occur for providers on military or maternity leave, requiring valid licensure verification before they resume care.

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    Test your knowledge with this practice exam flashcard set for the CPCS 2018 certification. Each flashcard provides crucial information regarding the accreditation of health care practitioners and their eligibility to participate in Federal health care programs. Prepare effectively for your upcoming certification exam with these key concepts.

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