CPCS CPCS - Certified Provider Credentialing Specialist Regulatory Requirements and Law Questions and Answers 2 — Questions and Answers
Question 1: Which federal law established the National Practitioner Data Bank and the peer review reporting system?
- HIPAA (Health Insurance Portability and Accountability Act)
- HCQIA (Health Care Quality Improvement Act of 1986) (Correct answer)
- ACA (Affordable Care Act)
- EMTALA (Emergency Medical Treatment and Active Labor Act)
Correct answer: HCQIA (Health Care Quality Improvement Act of 1986)
The Health Care Quality Improvement Act of 1986 (HCQIA) established the National Practitioner Data Bank and created the legal framework for peer review reporting and immunity.
The Health Care Quality Improvement Act of 1986 (HCQIA, 42 U.S.C. Section 11101 et seq.) created two major components: (1) the National Practitioner Data Bank (NPDB), which collects and discloses information about adverse actions and malpractice payments, and (2) a framework for providing immunity from damages for peer review activities conducted according to the Act's standards. HCQIA was motivated by concerns about incompetent physicians moving from state to state without detection. HIPAA addressed privacy; ACA addressed coverage; EMTALA addressed emergency treatment obligations.
Question 2: Under the Social Security Act, what is the penalty for knowingly employing or contracting with an excluded individual for items or services billable to Medicare or Medicaid?
- A warning letter for the first offense
- Civil monetary penalties of up to $20,000 per item or service rendered (Correct answer)
- Criminal prosecution only, no civil penalties
- No penalty if the organization was unaware of the exclusion
Correct answer: Civil monetary penalties of up to $20,000 per item or service rendered
Under the Civil Monetary Penalties Law (42 U.S.C. Section 1320a-7a), organizations can be assessed civil monetary penalties of up to $20,000 per item or service billed to Medicare or Medicaid that was rendered by an excluded individual.
The OIG has authority under the Civil Monetary Penalties Law (CMPL) to assess penalties against organizations that employ or contract with excluded individuals and submit claims to Medicare or Medicaid for their services. Penalties can include: civil monetary penalties of up to $20,000 per item or service billed, treble damages (three times the amount claimed for excluded services), and potential exclusion of the organization itself. The 'knew or should have known' standard applies, organizations are expected to check the LEIE regularly, so they cannot claim ignorance if they failed to screen.
Question 3: Which federal law requires covered entities to verify, before making payment, that providers are not excluded from participation in federal healthcare programs?
- HIPAA
- False Claims Act
- 42 CFR Part 1001
- Social Security Act, Section 1128 and 1156 (Correct answer)
Correct answer: Social Security Act, Section 1128 and 1156
Sections 1128 and 1156 of the Social Security Act establish the exclusion authorities and the requirement to deny payment for services rendered by excluded individuals.
The Social Security Act (SSA) contains the primary legal authority for Medicare and Medicaid exclusion: Section 1128 grants the Secretary of HHS authority to exclude individuals and entities from program participation; Section 1156 establishes obligations for Peer Review Organizations. The regulations implementing these exclusion authorities are found at 42 CFR Part 1001. The False Claims Act provides additional enforcement tools for fraudulent claims. HIPAA addresses privacy and portability. Together, these authorities create the legal framework for exclusion screening obligations.
Question 4: The anti-kickback statute (42 U.S.C. Section 1320a-7b) has implications for credentialing when:
- A hospital employs physicians and bills for their professional services
- A hospital grants privileges based on referral volume rather than clinical qualifications (Correct answer)
- All employment of credentialed physicians
- Board certification requirements are established for specific privileges
Correct answer: A hospital grants privileges based on referral volume rather than clinical qualifications
The anti-kickback statute prohibits inducements for referrals, including granting or maintaining privileges based on referral volume rather than clinical qualifications. Using privileges as a business incentive violates the statute.
While the anti-kickback statute primarily targets arrangements involving remuneration for referrals, it has implications for credentialing when privilege decisions are influenced by referral patterns rather than quality criteria. Using the grant, denial, or maintenance of clinical privileges as an inducement for or reward for patient referrals could constitute an improper inducement under the anti-kickback statute. This is one reason why privilege decisions must be based solely on objective clinical criteria established in advance, not on economic relationships or referral patterns.
Question 5: Which federal regulation requires hospitals to notify the NPDB within 15 days of accepting a practitioner's voluntary surrender of privileges while under investigation?
- HIPAA Privacy Rule
- 45 CFR Part 60 (NPDB regulations)
- 42 CFR Part 482 (Medicare Conditions of Participation)
- HCQIA Section 11133 (Correct answer)
Correct answer: HCQIA Section 11133
HCQIA Section 11133 (implemented at 42 CFR Part 60) requires hospitals to report to the NPDB when a practitioner voluntarily surrenders privileges while under investigation or to avoid investigation.
HCQIA Section 11133 establishes mandatory reporting requirements for hospitals, including the obligation to report to the NPDB when: (1) a practitioner's clinical privileges are reduced, restricted, suspended, revoked, or not renewed for more than 30 days due to professional competence or conduct reasons, or (2) a practitioner voluntarily surrenders privileges while under investigation or in return for not investigating. The implementing regulations at 45 CFR Part 60 specify the 15-calendar-day reporting deadline from the date the adverse action or voluntary surrender becomes final.
Question 6: Under the Americans with Disabilities Act (ADA), which inquiry is permissible during the credentialing process?
- Asking whether the practitioner has been treated for substance abuse in the past 5 years
- Asking whether the practitioner currently has a physical or mental condition that impairs their ability to perform the essential functions of their clinical privileges, with or without reasonable accommodation (Correct answer)
- Requiring disclosure of all prescription medications the practitioner takes
- Asking for a complete mental health history going back 10 years
Correct answer: Asking whether the practitioner currently has a physical or mental condition that impairs their ability to perform the essential functions of their clinical privileges, with or without reasonable accommodation
The ADA permits inquiry about current functional ability to perform essential job functions, but prohibits broad disability and medical history inquiries. Asking about current ability to perform clinical privileges is permissible.
The ADA limits the types of disability-related inquiries employers (and by extension, medical staff organizations) can make. Permissible inquiries include asking whether the practitioner currently has any physical or mental condition that would impair their ability to perform the essential functions of their requested privileges with or without reasonable accommodation, which is the standard attestation language on credentialing applications. Not permissible are: asking about past treatment for specific conditions, requiring disclosure of all medications, demanding complete medical/psychiatric history, or using disability history as a credentialing criterion unrelated to current functional ability.
CPCS CPCS - Certified Provider Credentialing Specialist Regulatory Requirements and Law Questions and Answers 2
Which federal law established the National Practitioner Data Bank and the peer review reporting system?