CPCS Knowledge 3 — Questions and Answers
Question 1: Which federal law established the Healthcare Integrity and Protection Data Bank (HIPDB), later merged with the NPDB?
- Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Correct answer)
- Medicare and Medicaid Patient and Program Protection Act of 1987
- Social Security Act Title XVIII
- Patient Protection and Affordable Care Act of 2010
Correct answer: Health Insurance Portability and Accountability Act (HIPAA) of 1996
HIPAA created the HIPDB to combat fraud and abuse; it was merged into the NPDB in 2013.
Question 2: A Credentials Verification Organization (CVO) that seeks NCQA certification must demonstrate what key capability?
- Maintaining a physical office in each state it serves
- Performing primary source verification according to NCQA's credentialing standards (Correct answer)
- Employing at least one licensed physician as a credentialing officer
- Holding accreditation from The Joint Commission
Correct answer: Performing primary source verification according to NCQA's credentialing standards
NCQA CVO certification requires the CVO to conduct primary source verification processes consistent with NCQA credentialing standards.
Question 3: Under The Joint Commission standards, which committee typically has final authority over clinical privileging decisions?
- The Quality Improvement Committee
- The Credentials Committee
- The Medical Executive Committee (MEC)
- The Governing Board (Correct answer)
Correct answer: The Governing Board
While the Medical Executive Committee recommends privileges, TJC standards place ultimate authority for granting, limiting, or revoking privileges with the Governing Board.
Question 4: A practitioner who holds a time-limited license with conditions imposed by the state board should trigger which credentialing action?
- Automatic approval if all other credentials are clean
- Immediate termination of the application
- Further investigation and reporting to the appropriate committee for review (Correct answer)
- Deferral pending the next re-credentialing cycle
Correct answer: Further investigation and reporting to the appropriate committee for review
A conditional or restricted license is a red flag that must be investigated and referred to the credentials or medical executive committee for a determination.
Question 5: What is the significance of the 'clean claims' period in the context of a practitioner's malpractice insurance verification?
- It refers to claims paid without dispute by the insurer
- It is the period without any reported malpractice claims used to assess risk history (Correct answer)
- It defines the tail coverage period required upon policy expiration
- It is the NPDB's reporting window for malpractice payments
Correct answer: It is the period without any reported malpractice claims used to assess risk history
A 'clean claims' period reflects years without malpractice claims, which credentialers use to evaluate a practitioner's liability risk profile.
Question 6: Which element is NOT typically required in an initial credentialing application for a physician?
- Current Drug Enforcement Administration (DEA) registration
- Evidence of current malpractice insurance coverage
- Proof of board certification in a specialty (Correct answer)
- Explanation of any gaps in clinical practice history
Correct answer: Proof of board certification in a specialty
Board certification is desirable but not universally required for credentialing; eligibility or lack of board certification must be addressed per the organization's criteria.
Question 7: Which statute requires hospitals that receive Medicare/Medicaid funds to query the NPDB when credentialing practitioners?
- HIPAA of 1996
- Medicare and Medicaid Patient and Program Protection Act of 1987 (Correct answer)
- Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985
- Patient Safety and Quality Improvement Act of 2005
Correct answer: Medicare and Medicaid Patient and Program Protection Act of 1987
The Medicare and Medicaid Patient and Program Protection Act of 1987 mandates that hospitals query the NPDB as part of the credentialing process.
CPCS Knowledge 3
Which federal law established the Healthcare Integrity and Protection Data Bank (HIPDB), later merged with the NPDB?