Regulatory Compliance & Verification Procedures Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Regulatory Compliance & Verification Procedures flashcards as text
Which credentialing concept allows a new medical staff member to begin practicing before full committee approval, under supervised conditions?
Answer: Provisional appointment with temporary privileges
Provisional appointments grant temporary privileges while the full credentialing process is completed, typically with oversight requirements.
Under The Joint Commission (TJC) standards, 'ongoing professional practice evaluation' (OPPE) is designed to:
Answer: Continuously monitor practitioner performance between re-credentialing cycles
OPPE is a continuous monitoring process using data to assess practitioner performance and inform re-credentialing decisions.
A practitioner fails to disclose a prior malpractice settlement on their credentialing application. Once discovered, this typically results in:
Answer: Immediate review for potential denial or revocation of privileges due to misrepresentation
Misrepresentation on a credentialing application is grounds for denial, revocation, or termination of medical staff membership.
The Sam-Day credentialing process used during disasters or emergencies is governed primarily by:
Answer: TJC Emergency Management standards and state emergency proclamations
Emergency or disaster credentialing is guided by TJC Emergency Management standards and activated state emergency declarations that relax standard procedures.
Which of the following best describes 'credentials by proxy' or 'delegated credentialing'?
Answer: A health plan accepts another organization's credentialing decision under a formal delegation agreement
Delegated credentialing allows a health plan to accept another entity's credentialing work when a formal oversight agreement is in place.
When must a hospital query the NPDB on an existing medical staff member, beyond initial appointment?
Answer: At least every two years and when a practitioner applies for new or expanded privileges
Hospitals must query the NPDB at re-appointment (at least every two years) and whenever a practitioner requests new or expanded clinical privileges.
Under NCQA, which of the following sources qualifies as primary source verification for board certification?
Answer: Direct query to the certifying specialty board (e.g., ABMS or AOA)
Primary source verification of board certification requires direct contact with the specialty board that issued the certification.