Regulatory Requirements and Law Flashcards

The Stark Law (42 U.S.C. §1395nn) primarily prohibits physician self-referrals for designated health services unless:

Answer: An applicable exception is met, such as the in-office ancillary services exception

Stark Law prohibits self-referrals for designated health services billed to Medicare/Medicaid unless a specific statutory or regulatory exception applies.

A credentialing specialist discovers that a practitioner failed to disclose a malpractice settlement on their application. Under most state laws, this constitutes:

Answer: Material misrepresentation, which is grounds for denial or termination

Intentional or negligent omission of required information on a credentialing application constitutes material misrepresentation and is grounds for denial, revocation, or termination of privileges under most state statutes and bylaws.

Which federal regulation at 42 CFR Part 2 specifically restricts the disclosure of patient records related to substance abuse treatment?

Answer: Confidentiality of Substance Use Disorder Patient Records (Part 2)

42 CFR Part 2 imposes stricter confidentiality requirements on substance use disorder treatment records than standard HIPAA protections, requiring patient consent for most disclosures.

When a hospital's medical staff bylaws conflict with state law regarding credentialing procedures, which generally takes precedence?

Answer: State law, because bylaws cannot require less than what law mandates

State law sets the minimum floor for credentialing procedures; medical staff bylaws may provide additional protections but cannot reduce rights granted by statute.

The False Claims Act allows private individuals to file lawsuits on behalf of the government against entities committing Medicare/Medicaid fraud. These individuals are known as:

Answer: Relators (qui tam plaintiffs)

Under the False Claims Act's qui tam provisions, private individuals (relators) can file suit on the government's behalf and receive a portion of any recovery.

A practitioner whose privileges are suspended for more than 30 days due to professional competence or conduct must be reported to the NPDB by:

Answer: The hospital or health plan that took the action

Hospitals and health plans must report to the NPDB any professional review action that adversely affects a practitioner's clinical privileges for more than 30 days.

Which principle requires that practitioners facing adverse credentialing actions receive notice of the charges, an opportunity to be heard, and a written decision with findings?

Answer: Due process

Due process (both constitutional and as codified in HCQIA) requires that practitioners subject to adverse actions receive adequate notice, a fair hearing, and a written decision explaining the outcome.