Regulatory Requirements and Law 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 Requirements and Law flashcards as text
Under HIPAA, which of the following is a permissible use of a practitioner's credentialing information without explicit authorization?
Answer: Disclosing credentialing status to another hospital for treatment or quality improvement purposes
HIPAA permits disclosure of credentialing information to other covered entities for treatment, payment, and healthcare operations purposes, including quality assessment activities.
The Medicare Conditions of Participation require that a hospital's medical staff bylaws be approved by the:
Answer: Governing body (board of directors) of the hospital
CMS Conditions of Participation (42 CFR §482.12) require that the hospital's governing body approve and be responsible for the medical staff bylaws and credentialing policies.
An anti-kickback statute violation in the credentialing context could arise if privileges are granted in exchange for:
Answer: A practitioner referring Medicare patients to the hospital's ancillary services
Conditioning privilege grants on referral commitments could violate the Anti-Kickback Statute if federal healthcare program patients are involved, as it constitutes remuneration to induce referrals.
Which law prohibits employment discrimination based on race, color, religion, sex, or national origin, and applies to credentialing decisions in qualifying healthcare organizations?
Answer: Title VII of the Civil Rights Act of 1964
Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on protected characteristics and applies to credentialing decisions in organizations with 15 or more employees.
A credentialing organization that shares peer review information with another hospital during a credentialing inquiry is generally protected from liability under:
Answer: State peer review confidentiality statutes
Most states have peer review confidentiality statutes that protect the sharing of quality assurance and credentialing information between healthcare entities from discovery and civil liability.
Under the ADA, a hospital is required to credential a practitioner with a disability if the practitioner:
Answer: Can perform the essential functions of the clinical privileges requested with or without reasonable accommodation
The ADA requires consideration of whether a practitioner can perform the essential functions of the requested privileges, with reasonable accommodation if needed, before making an adverse credentialing decision.
Which provision of the Affordable Care Act most directly affected credentialing by requiring health plans to establish provider credentialing standards and uniform credentialing applications?
Answer: Section 1311 (qualified health plan credentialing requirements)
ACA Section 1311 required qualified health plans operating in exchanges to meet credentialing standards, including using uniform credentialing applications established by HHS.