CPCS Regulatory Compliance & Verification Procedures 2 — Questions and Answers
Question 1: Under NCQA credentialing standards, what is the minimum acceptable primary source verification method for a physician's medical degree?
- Contacting the medical school registrar directly (Correct answer)
- Reviewing a photocopy of the diploma on file
- Accepting the applicant's sworn affidavit
- Using a secondary source such as a state board listing
Correct answer: Contacting the medical school registrar directly
NCQA requires direct contact with the primary source (the issuing medical school) to verify education credentials.
Question 2: Which federal law prohibits credentialing organizations from excluding providers from participation solely because they hold a specific type of license?
- Any Willing Provider laws (Correct answer)
- HIPAA Privacy Rule
- The Stark Law
- Anti-Kickback Statute
Correct answer: Any Willing Provider laws
Any Willing Provider laws require health plans to accept any licensed provider who meets their credentialing standards.
Question 3: A hospital discovers a practitioner's DEA registration expired 30 days ago. What is the immediate required action per standard credentialing policy?
- Suspend the practitioner's prescribing privileges pending DEA renewal (Correct answer)
- Allow continued prescribing while renewal is pending
- Terminate the practitioner's medical staff membership
- File a report with the state medical board immediately
Correct answer: Suspend the practitioner's prescribing privileges pending DEA renewal
An expired DEA registration means the practitioner lacks legal authority to prescribe controlled substances, requiring immediate privilege suspension.
Question 4: What is the purpose of querying the National Practitioner Data Bank (NPDB) during credentialing?
- To identify malpractice payments and adverse actions taken against practitioners (Correct answer)
- To verify current board certification status
- To confirm graduate medical education completion
- To check current hospital affiliations
Correct answer: To identify malpractice payments and adverse actions taken against practitioners
The NPDB contains reports of malpractice payments, licensure actions, and clinical privilege restrictions that must be reviewed during credentialing.
Question 5: Under CMS Conditions of Participation, hospitals must re-credential medical staff members at least every:
- 2 years (Correct answer)
- 1 year
- 3 years
- 5 years
Correct answer: 2 years
CMS Conditions of Participation require hospitals to re-appoint and re-credential medical staff at least every two years.
Question 6: Which verification procedure is used to confirm that a provider has not been excluded from participation in federal healthcare programs?
- OIG List of Excluded Individuals and Entities (LEIE) check (Correct answer)
- NPDB continuous query enrollment
- State license verification through primary source
- AMA Physician Masterfile query
Correct answer: OIG List of Excluded Individuals and Entities (LEIE) check
The OIG LEIE must be checked to ensure providers are not excluded from Medicare, Medicaid, and other federal programs.
Question 7: A credentialing specialist receives an application with a 6-month gap in employment history. The best course of action is to:
- Request a written explanation from the applicant covering the gap period (Correct answer)
- Automatically deny the application due to incomplete history
- Proceed with credentialing and note the gap in the file
- Contact state licensing boards to investigate the gap
Correct answer: Request a written explanation from the applicant covering the gap period
Credentialing standards require a complete work history, and unexplained gaps must be addressed through a written explanation from the applicant.
CPCS Regulatory Compliance & Verification Procedures 2
Under NCQA credentialing standards, what is the minimum acceptable primary source verification method for a physician's medical degree?