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

Which provision of the False Claims Act is most relevant to credentialing specialists ensuring that only properly credentialed practitioners bill Medicare?

Answer: The provision imposing liability for knowingly submitting false claims, including claims for services by non-credentialed or excluded practitioners

The False Claims Act imposes liability of up to three times the damages plus civil penalties for each false claim, which includes Medicare/Medicaid claims for services rendered by non-credentialed or excluded practitioners.

A state passes a 'any willing provider' law requiring all health plans to credential and include any licensed provider meeting the plan's quality standards. This type of law most directly affects which aspect of health plan credentialing?

Answer: The health plan's ability to limit its network based on non-quality business criteria

'Any willing provider' laws restrict a health plan's ability to exclude willing and qualified providers for non-clinical reasons, directly affecting network formation and credentialing decisions based on non-quality criteria.

Which accreditation standard is most directly aimed at preventing anti-competitive behavior in the credentialing and privileging process?

Answer: Requirements that privileging criteria be objective, written, and applied consistently to all applicants regardless of economic factors

Antitrust concerns require that privileging criteria be objective, written, consistently applied, and based on clinical qualifications, not economic status, referral patterns, or competitive relationships.

A credentialing specialist is asked to verify whether a practitioner is excluded from the Medicaid program in a different state than where the organization operates. What resource should be consulted?

Answer: The specific state's Medicaid exclusion list, as state lists may include exclusions not on the federal OIG LEIE

State Medicaid exclusion lists are maintained separately from the federal OIG LEIE and may include additional exclusions not reflected on the federal list. Both should be checked for complete coverage.

The Emergency Medical Treatment and Active Labor Act (EMTALA) has implications for hospital credentialing because:

Answer: It creates liability for hospitals when they fail to ensure on-call practitioners are properly credentialed and can fulfill on-call obligations

EMTALA requires hospitals with emergency departments to provide necessary stabilizing treatment and maintain an on-call list. Failure to ensure on-call practitioners are properly credentialed and able to fulfill EMTALA obligations creates hospital liability.

Which of the following correctly describes the 'peer review privilege' under state law and its significance for credentialing specialists?

Answer: It protects peer review materials and deliberations from discovery in civil litigation, encouraging frank participation in quality improvement

State peer review privilege laws protect materials and deliberations from peer review proceedings (including credentialing committee deliberations) from discovery in civil litigation, encouraging honest participation.