CPCS Credentialing Processes & Accreditation Standards 4 — Questions and Answers
Question 1: Which term describes the process of verifying a provider's credentials directly with the original issuing source?
- Secondary source verification
- Primary source verification (Correct answer)
- Tertiary verification
- Attestation
Correct answer: Primary source verification
Primary source verification means confirming credentials directly with the institution, licensing board, or organization that originally issued the credential.
Question 2: Ongoing Professional Practice Evaluation (OPPE) differs from FPPE in that OPPE:
- Is only required for new providers
- Is a continuous review of all practitioners with privileges (Correct answer)
- Is triggered only by a patient complaint
- Is performed solely by the credentials committee
Correct answer: Is a continuous review of all practitioners with privileges
OPPE is an ongoing, systematic review of all privileged practitioners to ensure continued competency, unlike FPPE which is time-limited for new privileges.
Question 3: A provider receives an adverse credentialing decision. Under HCQIA, the provider is entitled to:
- Immediate reinstatement pending appeal
- A fair hearing and appellate review (Correct answer)
- Access to all peer review records
- A jury trial within 90 days
Correct answer: A fair hearing and appellate review
HCQIA requires that providers subject to adverse professional review actions be given a fair hearing and appellate review opportunity.
Question 4: What does the term 'delineation of privileges' refer to in credentialing?
- Listing all states where a provider is licensed
- Specifying the exact clinical procedures and services a provider is authorized to perform (Correct answer)
- Describing a provider's educational background
- Outlining the provider's malpractice coverage limits
Correct answer: Specifying the exact clinical procedures and services a provider is authorized to perform
Delineation of privileges defines the specific clinical activities and procedures a practitioner is authorized to perform within a healthcare organization.
Question 5: Which organization maintains the Healthcare Sanctions database that credentialing specialists use to identify excluded providers?
- The Joint Commission
- Office of Inspector General (OIG) (Correct answer)
- Centers for Medicare & Medicaid Services (CMS)
- National Practitioner Data Bank (NPDB)
Correct answer: Office of Inspector General (OIG)
The OIG maintains the List of Excluded Individuals and Entities (LEIE), which identifies providers excluded from participation in federal healthcare programs.
Question 6: A telemedicine provider licensed in State A wants to practice in State B without obtaining a full license. Which mechanism may allow this?
- Interstate Compact for Telemedicine (Correct answer)
- Medical Staff Bylaws waiver
- CMS waiver program
- NPDB reciprocity agreement
Correct answer: Interstate Compact for Telemedicine
The Interstate Medical Licensure Compact (IMLC) streamlines the process for eligible physicians to obtain licenses in multiple member states, facilitating telemedicine practice.
Question 7: What is the purpose of a 'gap in practice' policy in credentialing?
- To excuse providers from re-credentialing if inactive less than one year
- To establish criteria for assessing competency when a provider has not practiced recently (Correct answer)
- To automatically deny privileges to providers inactive for more than six months
- To reduce malpractice insurance premiums for returning providers
Correct answer: To establish criteria for assessing competency when a provider has not practiced recently
Gap-in-practice policies define how organizations assess and verify current competency for providers returning after a period of inactivity.
CPCS Credentialing Processes & Accreditation Standards 4
Which term describes the process of verifying a provider's credentials directly with the original issuing source?