CPCS Credentialing Processes & Accreditation Standards 2 — Questions and Answers
Question 1: Which accreditation body sets standards for hospital credentialing programs in the United States?
- The Joint Commission (TJC) (Correct answer)
- National Committee for Quality Assurance (NCQA)
- URAC
- Accreditation Association for Ambulatory Health Care (AAAHC)
Correct answer: The Joint Commission (TJC)
The Joint Commission establishes and enforces credentialing standards for hospitals and other healthcare organizations seeking accreditation.
Question 2: What is the primary purpose of a Credentials Verification Organization (CVO)?
- To grant hospital privileges directly to providers
- To independently verify practitioner credentials on behalf of health plans or facilities (Correct answer)
- To license healthcare professionals at the state level
- To conduct peer review of clinical performance
Correct answer: To independently verify practitioner credentials on behalf of health plans or facilities
A CVO performs primary source verification and other credentialing functions as a delegated agent for health plans or healthcare organizations.
Question 3: Under NCQA standards, how often must a delegated credentialing entity submit an audit file to the delegating organization?
- Monthly
- Quarterly
- Annually (Correct answer)
- Every two years
Correct answer: Annually
NCQA requires delegating organizations to audit delegated entities at least annually to ensure compliance with credentialing standards.
Question 4: A provider's application reveals a malpractice settlement five years ago. What is the credentialing specialist's MOST appropriate next step?
- Automatically deny privileges based on the settlement
- Request the provider's explanation and obtain details of the settlement (Correct answer)
- Ignore it since it occurred more than three years ago
- Forward the application to legal counsel without further review
Correct answer: Request the provider's explanation and obtain details of the settlement
The specialist should gather complete information about the settlement, including the provider's explanation, before the credentials committee makes a determination.
Question 5: Which document establishes the criteria a medical staff must meet for granting clinical privileges?
- Bylaws and credentialing policies (Correct answer)
- The provider's curriculum vitae
- The facility's mission statement
- The state medical practice act alone
Correct answer: Bylaws and credentialing policies
Medical staff bylaws and credentialing policies define the criteria, process, and standards for granting, modifying, or denying clinical privileges.
Question 6: What is 'focused professional practice evaluation' (FPPE)?
- Ongoing monitoring of all medical staff performance
- A time-limited evaluation of a newly privileged or newly appointed practitioner (Correct answer)
- Annual peer review required by all accreditation bodies
- A disciplinary process for providers with patient complaints
Correct answer: A time-limited evaluation of a newly privileged or newly appointed practitioner
FPPE is a time-limited, focused evaluation process used to assess competence of practitioners who are new to an organization or who receive new privileges.
Question 7: Which federal law requires hospitals to report adverse credentialing actions to the National Practitioner Data Bank (NPDB)?
- HIPAA
- The Health Care Quality Improvement Act (HCQIA) (Correct answer)
- The Affordable Care Act
- The False Claims Act
Correct answer: The Health Care Quality Improvement Act (HCQIA)
The Health Care Quality Improvement Act of 1986 established the NPDB and mandates reporting of adverse actions against practitioners' clinical privileges.
CPCS Credentialing Processes & Accreditation Standards 2
Which accreditation body sets standards for hospital credentialing programs in the United States?