CPCS Regulatory Compliance & Verification Procedures 4 — Questions and Answers
Question 1: Which credentialing concept allows a new medical staff member to begin practicing before full committee approval, under supervised conditions?
- Provisional appointment with temporary privileges (Correct answer)
- Emergency privileges
- Expedited credentialing
- Reciprocal credentialing
Correct answer: Provisional appointment with temporary privileges
Provisional appointments grant temporary privileges while the full credentialing process is completed, typically with oversight requirements.
Question 2: Under The Joint Commission (TJC) standards, 'ongoing professional practice evaluation' (OPPE) is designed to:
- Continuously monitor practitioner performance between re-credentialing cycles (Correct answer)
- Replace the formal re-credentialing process every two years
- Evaluate only new or probationary medical staff members
- Document adverse events for state reporting purposes
Correct answer: Continuously monitor practitioner performance between re-credentialing cycles
OPPE is a continuous monitoring process using data to assess practitioner performance and inform re-credentialing decisions.
Question 3: A practitioner fails to disclose a prior malpractice settlement on their credentialing application. Once discovered, this typically results in:
- Immediate review for potential denial or revocation of privileges due to misrepresentation (Correct answer)
- A warning letter with a corrected application requirement
- Automatic suspension pending a state board investigation
- Referral to the NPDB for mandatory reporting
Correct answer: Immediate review for potential denial or revocation of privileges due to misrepresentation
Misrepresentation on a credentialing application is grounds for denial, revocation, or termination of medical staff membership.
Question 4: The Sam-Day credentialing process used during disasters or emergencies is governed primarily by:
- TJC Emergency Management standards and state emergency proclamations (Correct answer)
- Standard NCQA credentialing timelines
- CMS Conditions of Participation annual re-credentialing rules
- HIPAA emergency access provisions
Correct answer: TJC Emergency Management standards and state emergency proclamations
Emergency or disaster credentialing is guided by TJC Emergency Management standards and activated state emergency declarations that relax standard procedures.
Question 5: Which of the following best describes 'credentials by proxy' or 'delegated credentialing'?
- A health plan accepts another organization's credentialing decision under a formal delegation agreement (Correct answer)
- A practitioner authorizes a colleague to submit their credentials on their behalf
- A hospital delegates credentialing authority to department chiefs without committee oversight
- A state board certifies credentials on behalf of multiple licensing jurisdictions
Correct answer: A health plan accepts another organization's credentialing decision under a formal delegation agreement
Delegated credentialing allows a health plan to accept another entity's credentialing work when a formal oversight agreement is in place.
Question 6: When must a hospital query the NPDB on an existing medical staff member, beyond initial appointment?
- At least every two years and when a practitioner applies for new or expanded privileges (Correct answer)
- Only when a complaint or lawsuit is filed against the practitioner
- Annually regardless of any privilege changes
- Only at the time of initial appointment
Correct answer: At least every two years and when a practitioner applies for new or expanded privileges
Hospitals must query the NPDB at re-appointment (at least every two years) and whenever a practitioner requests new or expanded clinical privileges.
Question 7: Under NCQA, which of the following sources qualifies as primary source verification for board certification?
- Direct query to the certifying specialty board (e.g., ABMS or AOA) (Correct answer)
- A copy of the board certificate provided by the practitioner
- A letter from the practitioner's residency program director
- Verification through the AMA Physician Masterfile alone
Correct answer: Direct query to the certifying specialty board (e.g., ABMS or AOA)
Primary source verification of board certification requires direct contact with the specialty board that issued the certification.
CPCS Regulatory Compliance & Verification Procedures 4
Which credentialing concept allows a new medical staff member to begin practicing before full committee approval, under supervised conditions?