CPCS Accreditation Standards and Compliance 3 — Questions and Answers
Question 1: A provider's license was revoked in one state but they hold an active license in another state. What is the accreditation-required response when this is discovered during primary source verification?
- Proceed with credentialing using the active license only
- Report the finding to the credentials committee for review and decision (Correct answer)
- Automatically deny privileges without committee review
- Defer the credentialing decision for 90 days
Correct answer: Report the finding to the credentials committee for review and decision
A license revocation in any state is a red flag that must be reviewed by the credentials committee before a credentialing decision is made.
Question 2: Which federal database must be queried during the credentialing process to check for Medicare and Medicaid exclusions?
- National Practitioner Data Bank (NPDB)
- OIG List of Excluded Individuals and Entities (LEIE) (Correct answer)
- Federation of State Medical Boards (FSMB)
- American Medical Association (AMA) Masterfile
Correct answer: OIG List of Excluded Individuals and Entities (LEIE)
The OIG LEIE must be queried to identify providers excluded from participation in federal healthcare programs like Medicare and Medicaid.
Question 3: Which accreditation body uses the term 'deemed status' to allow its accredited hospitals to meet Medicare Conditions of Participation?
- NCQA
- URAC
- The Joint Commission (Correct answer)
- AAAHC
Correct answer: The Joint Commission
The Joint Commission holds CMS-granted deemed status, meaning TJC-accredited hospitals are considered to have met Medicare Conditions of Participation.
Question 4: An organization fails to complete recredentialing before a provider's two-year credentialing period expires. What is the accreditation-compliant action?
- Allow the provider to continue practicing under expired credentials until reviewed
- Suspend or restrict the provider's privileges until recredentialing is complete (Correct answer)
- Grant a blanket extension of 180 days automatically
- Transfer the file to legal for review
Correct answer: Suspend or restrict the provider's privileges until recredentialing is complete
Accreditation standards require that providers whose credentials have lapsed not be permitted to practice until recredentialing is successfully completed.
Question 5: What is the primary purpose of the Focused Professional Practice Evaluation (FPPE) required by TJC?
- To evaluate all practitioners on an ongoing quarterly basis
- To assess a practitioner's competence when granting new or initial privileges (Correct answer)
- To review malpractice claims annually
- To audit billing compliance for high-volume procedures
Correct answer: To assess a practitioner's competence when granting new or initial privileges
FPPE is a time-limited, focused review triggered by initial privilege granting or a specific concern about a practitioner's performance.
Question 6: When a credentialing application is incomplete, accreditation standards require the organization to:
- Deny the application and require resubmission
- Notify the applicant in writing of the missing information within a specified time frame (Correct answer)
- Proceed with available information and note gaps in the file
- Forward the incomplete file to the governing board for review
Correct answer: Notify the applicant in writing of the missing information within a specified time frame
Standards require timely written notification to the applicant identifying specific missing elements so the application can be completed.
Question 7: Which accreditation standard specifically addresses the requirement for a health plan to credential individual practitioners rather than credentialing only at the facility level?
- CMS Conditions of Participation
- NCQA HP Standards (Correct answer)
- OSHA General Duty Clause
- HIPAA Privacy Rule
Correct answer: NCQA HP Standards
NCQA Health Plan (HP) standards require health plans to individually credential practitioners in their network, not just rely on facility-level credentialing.
CPCS Accreditation Standards and Compliance 3
A provider's license was revoked in one state but they hold an active license in another state.
What is the accreditation-required response when this is discovered during primary source verification?