CPCS Reappointment and Recredentialing 4 — Questions and Answers
Question 1: An organization uses a 'clean file' exception to expedite reappointment for providers with no adverse findings. Which criterion would DISQUALIFY a provider from the clean file process?
- No malpractice claims in the prior appointment period
- Satisfactory OPPE scores across all competency domains
- A single unresolved patient complaint under investigation (Correct answer)
- Uninterrupted licensure with no board actions
Correct answer: A single unresolved patient complaint under investigation
An open or unresolved complaint or investigation disqualifies a provider from the expedited clean file process requiring full committee review.
Question 2: Which of the following BEST describes the relationship between OPPE and recredentialing?
- OPPE replaces the need for recredentialing every two years
- OPPE data informs the credentials committee's reappointment decision (Correct answer)
- OPPE is only required for physicians on probation
- OPPE is conducted by external peer reviewers during recredentialing
Correct answer: OPPE data informs the credentials committee's reappointment decision
OPPE provides ongoing performance data that the credentials committee uses as evidence when making reappointment decisions.
Question 3: A provider's reappointment file is complete except for one outstanding reference letter. The privilege period expires in five days. What is the most appropriate action?
- Grant full reappointment based on the available information
- Contact the reference directly to expedite the letter and follow the organization's incomplete application policy (Correct answer)
- Deny reappointment due to incomplete file
- Extend privileges indefinitely until the letter is received
Correct answer: Contact the reference directly to expedite the letter and follow the organization's incomplete application policy
The credentialing staff should actively pursue the missing reference and apply the organization's policy for incomplete applications to prevent a privilege lapse.
Question 4: A credentials committee member has a financial relationship with a provider whose reappointment is being reviewed. What must this committee member do?
- Recuse themselves from the discussion and vote on that provider's reappointment (Correct answer)
- Disclose the relationship but may still vote
- Vote against the provider to demonstrate impartiality
- Transfer the case to an outside credentials committee
Correct answer: Recuse themselves from the discussion and vote on that provider's reappointment
A committee member with a conflict of interest must recuse themselves from all deliberation and voting on that provider's reappointment.
Question 5: An organization learns mid-cycle that a provider's Drug Enforcement Administration (DEA) registration was revoked. Which action is required IMMEDIATELY?
- Wait until the next scheduled reappointment to address it
- Initiate a summary suspension of DEA-controlled substance prescribing privileges pending investigation (Correct answer)
- Report to the NPDB and take no further action
- Remove the provider from the medical staff roster
Correct answer: Initiate a summary suspension of DEA-controlled substance prescribing privileges pending investigation
DEA revocation requires immediate restriction of controlled substance prescribing authority pending a full investigation to protect patient safety.
Question 6: What does the term 'gap in practice' mean in the context of recredentialing, and why is it significant?
- A period when the provider did not bill for services, relevant to coding audits
- A period when the provider did not actively practice in their specialty, raising competency concerns (Correct answer)
- A gap in the NPDB query timeline requiring re-query
- A missing section in the reappointment application
Correct answer: A period when the provider did not actively practice in their specialty, raising competency concerns
A gap in practice is a period of clinical inactivity that may indicate competency concerns and typically requires additional evaluation such as proctoring or FPPE.
Question 7: When verifying a provider's current malpractice coverage during recredentialing, which element is MOST important to confirm?
- The name of the malpractice carrier
- That coverage limits meet the organization's minimum requirements and the policy is active (Correct answer)
- The number of claims filed against the provider
- Whether the carrier is rated A+ by AM Best
Correct answer: That coverage limits meet the organization's minimum requirements and the policy is active
Verifying that the malpractice policy is currently active and meets the organization's minimum coverage limits is the essential element of malpractice verification.
CPCS Reappointment and Recredentialing 4
An organization uses a 'clean file' exception to expedite reappointment for providers with no adverse findings.
Which criterion would DISQUALIFY a provider from the clean file process?