CPCS Negligent Credentialing and Legal Risk Management 4 — Questions and Answers
Question 1: A hospital grants expanded surgical privileges to a physician without requiring demonstration of competency in the new procedures. A patient is harmed. Which credentialing failure is MOST directly at issue?
- Failure to query the NPDB for new privileges
- Granting privileges beyond demonstrated current competence (Correct answer)
- Improper notification to the medical staff
- Failure to obtain malpractice insurance proof
Correct answer: Granting privileges beyond demonstrated current competence
Granting privileges without evidence of competency in the specific procedures is the classic negligent privileging failure.
Question 2: Which of the following actions by a medical staff member during peer review is MOST likely to eliminate HCQIA immunity protection?
- Recommending a 30-day summary suspension pending investigation
- Acting with the knowledge that the recommendation was false and motivated by personal animus (Correct answer)
- Failing to notify the affected physician 15 days before a hearing
- Conducting the review without a quorum of the peer review committee
Correct answer: Acting with the knowledge that the recommendation was false and motivated by personal animus
HCQIA immunity is lost if the action was taken in bad faith or with knowledge that the underlying information was false.
Question 3: A practitioner's malpractice insurer makes a payment on the practitioner's behalf. Who is responsible for reporting this to the NPDB?
- The hospital where the incident occurred
- The state medical board
- The malpractice insurance entity making the payment (Correct answer)
- The practitioner personally
Correct answer: The malpractice insurance entity making the payment
Under HCQIA, the malpractice insurance entity (insurer or self-insurer) making the payment must report it to the NPDB within 30 days.
Question 4: A physician is placed on a summary suspension pending investigation. What is the hospital's obligation regarding NPDB reporting at this stage?
- Immediate reporting is required upon any suspension
- Reporting is required only if the suspension exceeds 30 days or becomes a final adverse action (Correct answer)
- Reporting is required within 15 days of the summary suspension
- No reporting is required until the investigation concludes
Correct answer: Reporting is required only if the suspension exceeds 30 days or becomes a final adverse action
Summary suspensions pending investigation are reportable only if they result in a final adverse action exceeding 30 days.
Question 5: Which legal concept requires a physician whose privileges are under review to be given adequate notice and an opportunity to be heard before an adverse action becomes final?
- Informed consent doctrine
- Due process in peer review (fair hearing rights) (Correct answer)
- Respondeat superior
- EMTALA patient transfer requirements
Correct answer: Due process in peer review (fair hearing rights)
HCQIA and most medical staff bylaws require fair hearing rights—notice and an opportunity to be heard—before a final adverse credentialing action.
Question 6: A hospital system uses a centralized credentialing verification organization (CVO) to collect and verify credentials. If the CVO provides inaccurate information, who bears ultimate liability for a resulting credentialing error?
- The CVO exclusively, as the contracted party
- The individual credentialing specialist who relied on the CVO
- The hospital, which retains non-delegable responsibility for credentialing decisions (Correct answer)
- The state licensing board that issued the credentials
Correct answer: The hospital, which retains non-delegable responsibility for credentialing decisions
Hospitals cannot delegate away their corporate duty of care; they remain ultimately liable for credentialing decisions even when using a CVO.
Question 7: A practitioner's application reveals gaps in employment history. What is the credentialing specialist's BEST course of action?
- Deny the application for incompleteness
- Request written explanation for each gap and verify through additional references if needed (Correct answer)
- Ignore gaps of fewer than 6 months as immaterial
- Grant provisional privileges while gaps are investigated
Correct answer: Request written explanation for each gap and verify through additional references if needed
Unexplained gaps require written clarification and, if necessary, additional reference verification to ensure completency and patient safety.
CPCS Negligent Credentialing and Legal Risk Management 4
A hospital grants expanded surgical privileges to a physician without requiring demonstration of competency in the new procedures.
A patient is harmed.
Which credentialing failure is MOST directly at issue?