CPCS Basic 3 — Questions and Answers
Question 1: Which federal law established the NPDB and requires hospitals to query it before granting privileges?
- HIPAA
- The Health Care Quality Improvement Act of 1986 (Correct answer)
- The Affordable Care Act
- The Social Security Act
Correct answer: The Health Care Quality Improvement Act of 1986
The Health Care Quality Improvement Act of 1986 created the NPDB and mandated that hospitals query it when practitioners apply for or renew clinical privileges.
Question 2: What is the credentialing term for a formal agreement between two organizations where one performs credentialing on behalf of the other?
- Delegated credentialing (Correct answer)
- Reciprocal credentialing
- Provisional credentialing
- Courtesy credentialing
Correct answer: Delegated credentialing
Delegated credentialing is a contractual arrangement where an MCO delegates credentialing functions to a hospital, IPA, or group practice that performs them under agreed-upon standards.
Question 3: Which of the following best describes 'sanctions' in the context of provider credentialing?
- Awards given for excellent patient outcomes
- Punitive actions taken by government or professional bodies against a provider (Correct answer)
- Insurance premium adjustments
- Voluntary resignations from medical staff
Correct answer: Punitive actions taken by government or professional bodies against a provider
Sanctions are formal disciplinary actions imposed by government agencies, licensing boards, or professional organizations that restrict or penalize a provider's practice.
Question 4: The OIG List of Excluded Individuals and Entities (LEIE) is checked during credentialing to ensure:
- The provider has adequate malpractice insurance
- The provider is not barred from participating in federal healthcare programs (Correct answer)
- The provider's medical school is accredited
- The provider has no outstanding student loans
Correct answer: The provider is not barred from participating in federal healthcare programs
Providers on the OIG LEIE are excluded from participating in Medicare, Medicaid, and other federal healthcare programs, making this check mandatory during credentialing.
Question 5: What type of malpractice insurance policy covers claims only if both the incident AND the claim occur while the policy is active?
- Occurrence policy
- Claims-made policy (Correct answer)
- Tail coverage policy
- Umbrella policy
Correct answer: Claims-made policy
A claims-made policy only covers claims made (filed) during the active policy period, as opposed to an occurrence policy that covers incidents that occurred during the policy period regardless of when claimed.
Question 6: In credentialing, what does 'peer references' primarily assess?
- A provider's billing accuracy
- Clinical competence and professional conduct as observed by colleagues (Correct answer)
- Malpractice history
- Academic training credentials
Correct answer: Clinical competence and professional conduct as observed by colleagues
Peer references are collected from colleagues who have direct knowledge of the applicant's clinical skills, judgment, and professional behavior in practice settings.
Question 7: Which accrediting body specifically focuses on utilization management and case management organizations, in addition to credentialing?
- NCQA
- The Joint Commission
- URAC (Correct answer)
- DNV GL
Correct answer: URAC
URAC (formerly Utilization Review Accreditation Commission) accredits organizations for utilization management, case management, and credentialing, among other health care functions.
CPCS Basic 3
Which federal law established the NPDB and requires hospitals to query it before granting privileges?