CPCS Negligent Credentialing and Legal Risk Management 5 — Questions and Answers
Question 1: A telemedicine physician is credentialed at a distant-site hospital and provides services to a patient at an originating-site critical access hospital. Under CMS rules, what credentialing option is available to the originating site?
- The originating site must independently credential the telemedicine physician as a full medical staff member
- The originating site may rely on the distant site's credentialing and privileging decisions through a written agreement (Correct answer)
- Telemedicine physicians are exempt from credentialing requirements entirely
- The originating site must use a third-party CVO to credential all telemedicine providers
Correct answer: The originating site may rely on the distant site's credentialing and privileging decisions through a written agreement
CMS Conditions of Participation permit originating-site hospitals to accept the distant site's credentialing and privileging through a formal written agreement.
Question 2: Which standard of care for negligent credentialing cases is MOST commonly applied by courts when assessing what a hospital 'should have known'?
- What an identical hospital in the same city would have done
- What a reasonably prudent hospital with similar resources would have done (Correct answer)
- What the best academic medical center in the country would have done
- What the hospital's own bylaws required at the time
Correct answer: What a reasonably prudent hospital with similar resources would have done
Courts typically apply a 'reasonably prudent hospital' standard, considering resources and national standards rather than only local practice.
Question 3: A hospital receives a credentialing application from a physician who graduated from a foreign medical school. Which primary source verification step is MOST critical for confirming the validity of the degree?
- Verifying malpractice history through the NPDB
- Contacting the Educational Commission for Foreign Medical Graduates (ECFMG) (Correct answer)
- Requesting a copy of the diploma directly from the physician
- Confirming state licensure through the medical board
Correct answer: Contacting the Educational Commission for Foreign Medical Graduates (ECFMG)
ECFMG certification is the authoritative primary source verification for foreign medical graduates' education and training credentials.
Question 4: Under the Ongoing Professional Practice Evaluation (OPPE) framework, data collected on a practitioner must be used for what purpose?
- To set the practitioner's compensation
- To inform reappointment and privilege renewal decisions (Correct answer)
- To generate public performance reports for patients
- To determine medical malpractice premium rates
Correct answer: To inform reappointment and privilege renewal decisions
OPPE data is explicitly required to inform decisions about continuation of privileges at reappointment.
Question 5: A state court applies a 'some evidence' standard when a physician challenges a hospital's decision to deny privileges. What does this standard mean for the hospital?
- The hospital must prove denial was correct by clear and convincing evidence
- The court will uphold the denial if any credible evidence in the record supports it (Correct answer)
- The physician bears the burden of proving no evidence justified denial
- The hospital must show a preponderance of evidence that denial was warranted
Correct answer: The court will uphold the denial if any credible evidence in the record supports it
The 'some evidence' standard is highly deferential—courts will not second-guess a privilege denial if the record contains any credible supporting evidence.
Question 6: Which scenario MOST clearly demonstrates 'red flags' that should trigger enhanced due diligence in credentialing?
- A physician who practiced in only one state for 20 years
- An application with references from the physician's personal colleagues only, combined with an unexplained 2-year gap (Correct answer)
- A physician applying for privileges in the same specialty as an existing staff member
- Malpractice tail coverage purchased at the end of a prior employment
Correct answer: An application with references from the physician's personal colleagues only, combined with an unexplained 2-year gap
Biased references combined with unexplained employment gaps are classic red flags requiring additional verification and inquiry.
Question 7: A credentialing specialist receives a confidential reference that raises serious concerns about a physician's clinical judgment. The physician is not aware of this reference. What ethical and legal obligation guides how this information should be used?
- The reference must be discarded because the physician cannot respond to it
- The information should be weighed in the overall credentialing decision within the confidential peer review process (Correct answer)
- The specific reference must be disclosed to the physician before any decision is made
- Confidential references carry no legal weight and must be verified through non-confidential sources
Correct answer: The information should be weighed in the overall credentialing decision within the confidential peer review process
Confidential peer review references are legitimately considered in credentialing decisions; most bylaws and state peer review laws protect their confidentiality while allowing their use.
CPCS Negligent Credentialing and Legal Risk Management 5
A telemedicine physician is credentialed at a distant-site hospital and provides services to a patient at an originating-site critical access hospital.
Under CMS rules, what credentialing option is available to the originating site?