CPCS Accreditation Standards and Compliance 4 — Questions and Answers
Question 1: A credentialing specialist discovers that a provider's malpractice insurance has lapsed mid-credentialing cycle. What is the compliance-required immediate action?
- Notify the credentials committee and suspend privileges pending proof of coverage (Correct answer)
- Allow 90 days for the provider to reinstate coverage before taking action
- Send a courtesy notice but allow practice to continue
- Initiate peer review proceedings
Correct answer: Notify the credentials committee and suspend privileges pending proof of coverage
Active malpractice coverage is a continuous credentialing requirement; lapsed coverage requires immediate notification to the committee and suspension of privileges.
Question 2: Under NCQA standards, which body is ultimately responsible for approving or denying credentials for practitioners in a health plan network?
- The credentialing specialist
- The medical director alone
- The credentials committee or delegated credentialing entity (Correct answer)
- The state medical board
Correct 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.
Question 3: What must a hospital do when it identifies a potential patient safety issue through the OPPE process for a credentialed provider?
- Wait until the next recredentialing cycle to address the concern
- Initiate an FPPE to investigate the specific concern (Correct answer)
- Immediately revoke the provider's privileges without review
- Report directly to the NPDB without internal review
Correct answer: Initiate an FPPE to investigate the specific concern
OPPE findings that raise safety concerns trigger an FPPE to conduct a focused, time-limited investigation before any privilege action.
Question 4: Which accreditation standard governs how an organization must handle a provider's request for a hearing following an adverse credentialing action?
- CMS Conditions of Participation 42 CFR 482.22
- Health Care Quality Improvement Act (HCQIA) fair hearing requirements (Correct answer)
- HIPAA Security Rule
- EMTALA regulations
Correct 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.
Question 5: A delegated credentialing organization fails a NCQA delegation audit. What is the health plan's required response?
- Allow the delegate to self-correct over the next audit cycle
- Terminate the delegation agreement immediately
- Conduct an oversight audit and develop a corrective action plan with the delegate (Correct answer)
- Transfer all credentialing files to a new delegate without notification
Correct 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.
Question 6: Which document serves as the primary governance instrument establishing the structure and authority of a hospital medical staff credentialing process?
- The credentialing policy and procedure manual
- The medical staff bylaws (Correct answer)
- The department-specific privileging criteria
- The accreditation survey report
Correct answer: The medical staff bylaws
Medical staff bylaws are the foundational governance document that establishes the authority, structure, and processes governing credentialing and privileging.
Question 7: When an accreditation surveyor reviews credentialing files, which finding would most likely result in a Requirement for Improvement (RFI) under TJC standards?
- A file containing more reference letters than required
- Primary source verification completed by phone call with verbal confirmation
- Missing written confirmation of primary source verification for a provider's medical degree (Correct answer)
- A signed query to the NPDB dated one week before the credentialing decision
Correct answer: Missing written confirmation of primary source verification for a provider's medical degree
Absent documentation of primary source verification for required credentials like a medical degree is a direct standards violation resulting in an RFI.
CPCS Accreditation Standards and Compliance 4
A credentialing specialist discovers that a provider's malpractice insurance has lapsed mid-credentialing cycle.
What is the compliance-required immediate action?