CPCS Provider Enrollment and Payer Credentialing Processes 5 — Questions and Answers
Question 1: What is the purpose of conducting an 'OIG exclusion check' during provider enrollment?
- To verify the provider's NPI is active and valid
- To confirm the provider is not banned from participating in federal healthcare programs (Correct answer)
- To check whether the provider has a valid DEA registration
- To verify the provider's board certification status
Correct answer: To confirm the provider is not banned from participating in federal healthcare programs
The OIG List of Excluded Individuals/Entities (LEIE) identifies providers and entities banned from participation in Medicare, Medicaid, and other federal healthcare programs due to fraud, abuse, or other violations.
Question 2: A critical access hospital (CAH) is credentialing a telemedicine physician employed by a distant-site hospital. Which accreditation standard allows the CAH to rely on the distant site's credentialing?
- URAC Telemedicine Standard 4.2
- CMS Conditions of Participation telemedicine credentialing provisions (Correct answer)
- The Joint Commission's Remote Practitioner Standard RI.01.07.01
- NCQA Health Plan Accreditation Standard CR 3
Correct answer: CMS Conditions of Participation telemedicine credentialing provisions
CMS Conditions of Participation allow critical access hospitals to grant privileges to telemedicine physicians based on the distant-site hospital's credentialing and privileging decisions under a written agreement.
Question 3: During re-credentialing, a physician discloses a new DUI conviction that occurred 18 months ago. What is the MOST appropriate next step for the credentialing specialist?
- Immediately revoke the physician's privileges without further review
- Refer the disclosure to the credentialing committee for individualized review per established policy (Correct answer)
- Ignore it since it is not a medical offense
- Report it to the NPDB as an adverse action
Correct answer: Refer the disclosure to the credentialing committee for individualized review per established policy
Criminal convictions disclosed during re-credentialing must be referred to the credentialing committee for individualized review according to the organization's established policies and bylaws.
Question 4: Which term describes the process where a provider is granted temporary practice privileges while full credentialing verification is still in progress?
- Conditional enrollment
- Provisional or temporary privileges (Correct answer)
- Expedited credentialing
- Locum tenens licensure
Correct answer: Provisional or temporary privileges
Provisional or temporary privileges allow a provider to begin practicing while the full credentialing process is completed, typically subject to specific conditions and time limits set by the organization.
Question 5: A payer's contract stipulates a 'most favored nation' (MFN) clause. How does this affect provider enrollment strategy?
- The provider must enroll in all of the payer's network tiers simultaneously
- The provider cannot charge this payer more than the lowest rate given to any other payer (Correct answer)
- The provider receives the highest reimbursement rate available in their market
- The provider must enroll all practitioners in the group under a single contract
Correct answer: The provider cannot charge this payer more than the lowest rate given to any other payer
A most favored nation clause requires the provider to give the contracting payer rates no higher than the lowest rates offered to any other commercial payer, which constrains negotiation flexibility across payer contracts.
Question 6: Under NCQA standards for health plan credentialing, how often must providers be re-credentialed at minimum?
- Annually
- Every two years
- Every three years (Correct answer)
- Every five years
Correct answer: Every three years
NCQA requires health plans to re-credential practitioners at least every three years to ensure ongoing compliance with credentialing standards and to identify any changes in practitioners' qualifications.
Question 7: A provider enrollment specialist is onboarding a new nurse practitioner (NP) who will practice in a state with 'full practice authority.' What does this mean for their enrollment and supervision documentation?
- The NP must have a supervising physician co-sign all enrollment applications
- The NP can enroll independently and practice without a required physician collaboration or supervision agreement (Correct answer)
- The NP must submit a collaborative practice agreement to all payers
- The NP is restricted to hospital-based practice only
Correct answer: The NP can enroll independently and practice without a required physician collaboration or supervision agreement
In full practice authority states, NPs can evaluate, diagnose, and treat patients independently without a required physician collaboration agreement, simplifying their enrollment and credentialing process.
CPCS Provider Enrollment and Payer Credentialing Processes 5
What is the purpose of conducting an 'OIG exclusion check' during provider enrollment?