Mixed Deck — All CPCS Topics Flashcards
100 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 20 Mixed Deck — All CPCS Topics flashcards as text
Which organization publishes the USMLE Step examinations used to verify physician competency?
Answer: National Board of Medical Examiners (NBME) and FSMB jointly
The USMLE is co-sponsored by the NBME and the Federation of State Medical Boards (FSMB).
An NPDB query is completed after disaster privileges have already been granted, and it reveals significant adverse action history. What is the appropriate response?
Answer: Immediately notify the CEO and medical staff leadership so the privileges can be reviewed and potentially revoked
Patient safety requires prompt action whenever adverse information is discovered about a privileged practitioner; the CEO and medical staff leadership must be notified immediately to determine whether privileges should be continued or revoked.
How many times must the license be validated with the primary source according to the Joint Commission's requirements?
Answer: Everything mentioned above
The Joint Commission mandates primary source verification of a practitioner's license at several critical junctures. This includes the initial granting of privileges, subsequent reappointment cycles, any change in the license's status (e.g., restrictions or disciplinary actions), and when a practitioner relocates to a different state. This comprehensive approach ensures continuous compliance and patient safety by confirming the practitioner's legal authorization to practice.
Under NCQA standards, which body is ultimately responsible for approving or denying credentials for practitioners in a health plan network?
Answer: The credentials committee or delegated credentialing entity
NCQA requires that a credentials committee or properly delegated entity—not an individual—make final credentialing decisions.
A hospital grants a physician privileges for a procedure that the physician is not competent to perform, and the patient suffers injury. Under what legal theory is the hospital most directly liable?
Answer: Corporate negligence (negligent credentialing)
Corporate negligence or negligent credentialing holds hospitals directly liable for failing to properly investigate and ensure the competency of practitioners to whom they grant privileges.
Which of the following is the BEST definition of 'credentialing' as it applies to healthcare organizations?
Answer: The process of collecting, verifying, and assessing qualifications of practitioners to determine if they meet an organization's standards for appointment or participation
Healthcare credentialing is the formal process of gathering, verifying, and evaluating practitioner qualifications against an organization's standards to determine eligibility for appointment, network participation, or clinical privileges.
A practitioner at reappointment discloses a malpractice case that settled 18 months ago, which was also reported to the NPDB. The NPDB report shows the case involved a surgical complication. How should the credentials committee approach this disclosure?
Answer: Review the case details, OPPE data related to surgical outcomes, and peer input to make a holistic reappointment decision
The credentials committee should conduct a holistic review that includes the case details, the practitioner's surgical OPPE data, peer input, and any corrective actions taken. Malpractice history alone does not determine reappointment.
Which credentialing concept describes granting temporary privileges to a practitioner during a disaster or emergency situation?
Answer: Emergency privileges
Emergency privileges allow organizations to rapidly credential practitioners during disasters or emergencies when normal processes cannot be completed in time.
A delegated credentialing organization fails a NCQA delegation audit. What is the health plan's required response?
Answer: Conduct an oversight audit and develop a corrective action plan with the delegate
NCQA requires the health plan to conduct oversight, document deficiencies, and work with the delegate on a corrective action plan when audit failures occur.
Which federal agency oversees the NPDB and has authority to impose civil monetary penalties on entities that fail to report required information?
Answer: The Health Resources and Services Administration (HRSA)
HRSA administers the NPDB and has authority to investigate violations and impose civil monetary penalties on entities that fail to report required adverse actions and malpractice payments.
Under HIPAA, who is authorized to access a provider's credentialing file containing peer reference letters?
Answer: Only those with a legitimate need-to-know role in the credentialing process
Access to credentialing files must be restricted to individuals with a documented, role-based need to know.
Which organization publishes the Credentials Verification Organization (CVO) certification program?
Answer: NCQA
NCQA certifies CVOs through its CVO Certification program to standardize credentialing verification.
A provider's reappointment file reveals a pattern of late medical record completion. Which entity within the medical staff structure is MOST appropriate to address this as a performance concern?
Answer: Department chair or peer review committee
Performance-based concerns identified at reappointment are typically referred to the department chair or peer review/quality committee for evaluation and action.
Board certification is not mentioned in the CMS requirements expressly. The medical staff must take into account all aspects of training and professional education when making recommendations; they cannot rely their decisions only on board certification.
Answer: Board certification confirmation in accordance with CMS
The Centers for Medicare & Medicaid Services (CMS) does not explicitly require board certification for practitioners. Instead, CMS mandates that the medical staff consider all aspects of a practitioner's training and professional education when making recommendations for privileges. Decisions cannot be based solely on board certification, emphasizing a comprehensive evaluation of qualifications to ensure patient safety and quality of care for Medicare/Medicaid beneficiaries.
A Central Processing and Credentialing Specialist (CPCS) discovers that a physician's privileges were granted without the required peer review committee approval due to a workflow gap. What is the most appropriate immediate action?
Answer: Notify the Chief Medical Officer and Medical Staff Office leadership, then convene an emergency peer review to ratify or rescind the privileges
When a compliance gap is discovered — such as privileges granted without required peer review — the CPCS must escalate immediately to organizational leadership (CMO and Medical Staff Office) and trigger an emergency review. Continuing to allow practice without correction exposes the organization to liability; retroactive documentation is fraudulent; and external reporting before internal resolution bypasses governance protocols.
Which federal law established the National Practitioner Data Bank (NPDB) and mandated reporting of certain adverse actions?
Answer: Health Care Quality Improvement Act of 1986
The Health Care Quality Improvement Act of 1986 (HCQIA) established the NPDB and created mandatory reporting requirements for malpractice payments and adverse privilege actions.
Which accreditation standard governs how an organization must handle a provider's request for a hearing following an adverse credentialing action?
Answer: Health Care Quality Improvement Act (HCQIA) fair hearing requirements
HCQIA establishes the fair hearing and appeals process that hospitals must follow when taking adverse professional review actions against practitioners.
A credentialing specialist discovers that a practitioner's DEA certificate will expire in 45 days. The practitioner has not yet started the renewal process. What action should the specialist take?
Answer: Notify the practitioner in writing and document the notification in the credentialing file
The specialist should notify the practitioner in writing about the upcoming expiration, request evidence of renewal application or renewed certificate, and document the notification and follow-up in the credentialing file.
What is the maximum period for which temporary privileges may be granted under standard hospital policy aligned with Joint Commission standards?
Answer: 90 days, with the possibility of one renewal
Joint Commission standards allow temporary privileges for a period not to exceed 120 days total, often implemented as an initial 90-day grant with one 30-day renewal.
A credentialing specialist is verifying a physician's board certification through the ABMS website and finds that the certification has lapsed due to failure to complete Maintenance of Certification (MOC) requirements. How should this be handled?
Answer: The file should document the lapsed certification and the credentials committee should evaluate the significance for privileging purposes
Lapsed board certification is a finding that must be documented in the credentialing file and presented to the credentials committee for evaluation of its significance for specific privilege requests.