CPCS Clinical Privileging 5 — Questions and Answers
Question 1: A provider's privileges are restricted pending a peer review investigation. The provider demands an immediate fair hearing. At what point is a provider entitled to a fair hearing?
- Any time a restriction is placed on their privileges
- Only when a restriction or denial is likely to be reported to the NPDB
- Only after the investigation is complete and a formal adverse recommendation is made
- When a summary suspension exceeds 14 days (Correct answer)
Correct answer: When a summary suspension exceeds 14 days
Under HCQIA, a provider is entitled to a hearing when a summary suspension exceeds 30 days, or more commonly under medical staff bylaws when it exceeds 14 days or when a formal adverse action is recommended.
Question 2: What is the primary purpose of querying the NPDB at the time of initial application for privileges?
- To determine the provider's malpractice insurance rates
- To identify prior adverse actions, malpractice payments, and licensure actions not disclosed by the provider (Correct answer)
- To satisfy state licensing board requirements for hospital employment
- To verify primary source information about residency training
Correct answer: To identify prior adverse actions, malpractice payments, and licensure actions not disclosed by the provider
An NPDB query at initial application reveals any previously reported adverse privileging actions, malpractice payments, or licensure sanctions that a provider may not have disclosed.
Question 3: A physician holds privileges at two hospitals within the same health system. One hospital initiates a summary suspension. What must the second hospital do?
- Automatically suspend the physician's privileges at the second hospital as well
- Take no action until the first hospital's investigation is complete
- Be notified and independently evaluate whether action is warranted (Correct answer)
- Transfer all care responsibilities to the first hospital
Correct answer: Be notified and independently evaluate whether action is warranted
While automatic cross-facility suspension is not universally required, the second hospital must be notified and should independently assess whether patient safety warrants action at its facility.
Question 4: Which metric is typically NOT appropriate for inclusion in an OPPE data profile for a surgeon?
- Surgical site infection rates
- Case volume by procedure type
- The surgeon's annual continuing medical education hours (Correct answer)
- Readmission rates within 30 days of surgery
Correct answer: The surgeon's annual continuing medical education hours
CME hours are a credentialing input and a licensure requirement, not a performance outcome metric appropriate for OPPE, which focuses on clinical performance indicators.
Question 5: A hospital grants privileges to an advanced practice registered nurse (APRN) who will practice independently in an outpatient clinic. Which standard governs the privileging process for this provider?
- The same credentialing and privileging standards that apply to physicians (Correct answer)
- APRN-specific privileging standards that differ from those applied to physicians
- Only state nursing board regulations, not hospital privileging standards
- The CMS guidelines for non-physician practitioners in outpatient settings
Correct answer: The same credentialing and privileging standards that apply to physicians
Joint Commission and CMS standards require that APRNs granted clinical privileges undergo a credentialing and privileging process equivalent to that applied to physicians.
Question 6: A credentials specialist discovers that a physician's board certification lapsed two years ago and the physician did not disclose this. What should happen next?
- Immediately revoke the physician's privileges pending board recertification
- Notify the credentials committee and department chair so they can determine whether continued privileges are appropriate (Correct answer)
- Update the file and note the lapse without further action
- Automatically report the lapse to the NPDB
Correct answer: Notify the credentials committee and department chair so they can determine whether continued privileges are appropriate
Lapsed board certification and non-disclosure must be escalated to the credentials committee and department chair to assess whether the physician still meets the criteria for their granted privileges.
Question 7: Which of the following best describes 'low-volume' or 'threshold' privileging criteria?
- Criteria that restrict privileges to providers who perform procedures only in high-volume settings
- Minimum case volume requirements that a provider must meet to be eligible for or maintain specific privileges (Correct answer)
- Criteria used to determine whether a hospital should offer a low-volume service line
- Benchmarks comparing a provider's volume to national norms for OPPE purposes
Correct answer: Minimum case volume requirements that a provider must meet to be eligible for or maintain specific privileges
Volume threshold criteria establish a minimum number of procedures a provider must have performed to demonstrate sufficient competency to be granted or maintain a specific privilege.
CPCS Clinical Privileging 5
A provider's privileges are restricted pending a peer review investigation.
The provider demands an immediate fair hearing.
At what point is a provider entitled to a fair hearing?