CPCS Initial Application Processing 4 — Questions and Answers
Question 1: What is the significance of the OIG List of Excluded Individuals/Entities (LEIE) in initial credentialing?
- It lists providers who have been board-certified
- It identifies individuals and entities excluded from participating in federal healthcare programs (Correct answer)
- It tracks providers with active malpractice suits
- It logs all providers with expired licenses
Correct answer: It identifies individuals and entities excluded from participating in federal healthcare programs
The OIG LEIE must be queried to ensure the provider is not excluded from participation in Medicare, Medicaid, or other federal healthcare programs.
Question 2: Which credentialing standard requires organizations to have a mechanism for providers to correct inaccuracies in their application?
- Fair Hearing and Appeals Plan (Correct answer)
- Ongoing Professional Practice Evaluation (OPPE)
- Focused Professional Practice Evaluation (FPPE)
- Primary Source Verification protocol
Correct answer: Fair Hearing and Appeals Plan
The Fair Hearing and Appeals Plan ensures providers have due process rights, including the ability to challenge and correct adverse credentialing decisions or inaccuracies.
Question 3: A provider's application lists board certification as 'in progress.' How should this be documented during the initial credentialing process?
- Record it as verified and move forward
- Document the pending status and note that certification must be verified before privileges are granted or at defined deadline (Correct answer)
- Deny the application until board certification is complete
- List it as unverifiable and flag for committee review only
Correct answer: Document the pending status and note that certification must be verified before privileges are granted or at defined deadline
Pending board certification should be documented with any applicable deadlines, and the organization's policy determines whether temporary privileges may be granted during the process.
Question 4: Under The Joint Commission standards, how often must primary source verification be completed for an existing license that has already been verified?
- Every 6 months
- At each reappointment cycle, typically every 2 years (Correct answer)
- Only at initial appointment and never again
- Annually, regardless of reappointment cycle
Correct answer: At each reappointment cycle, typically every 2 years
TJC standards require re-verification of ongoing licensure at each reappointment, which typically occurs every two years.
Question 5: What is the purpose of the 'release and consent' section of an initial credentialing application?
- It authorizes the organization to bill the provider's insurance
- It allows the organization to contact references and release information to third parties during the credentialing process (Correct answer)
- It grants the provider temporary clinical privileges immediately
- It waives the provider's right to a fair hearing
Correct answer: It allows the organization to contact references and release information to third parties during the credentialing process
The release and consent section authorizes the organization to perform background checks, contact references, and share credentialing information with authorized parties.
Question 6: When a provider fails to disclose a prior license sanction on their application, what potential consequence may they face?
- A mandatory 30-day suspension of privileges
- Application denial or revocation of privileges for providing false information (Correct answer)
- A required continuing education course on ethics
- Automatic referral to the DEA for investigation
Correct answer: Application denial or revocation of privileges for providing false information
Providing false or incomplete information on a credentialing application can result in denial of the application or revocation of privileges already granted.
Question 7: Which of the following best describes a 'focused professional practice evaluation' (FPPE) in relation to initial credentialing?
- A routine annual review of all privileged providers
- A time-limited monitoring period for providers newly granted clinical privileges (Correct answer)
- A peer review of malpractice cases only
- A credentialing review triggered by patient complaints
Correct answer: A time-limited monitoring period for providers newly granted clinical privileges
FPPE is a structured evaluation period for new applicants or providers receiving new privileges to confirm competency before full independent practice.
CPCS Initial Application Processing 4
What is the significance of the OIG List of Excluded Individuals/Entities (LEIE) in initial credentialing?