CPCS Regulatory Requirements and Law 3 — Questions and Answers
Question 1: The Stark Law (42 U.S.C. §1395nn) primarily prohibits physician self-referrals for designated health services unless:
- The referral is for fewer than 10 patients per year
- An applicable exception is met, such as the in-office ancillary services exception (Correct answer)
- The physician has held privileges at the facility for over five years
- The referring physician holds board certification in the relevant specialty
Correct answer: An applicable exception is met, such as the in-office ancillary services exception
Stark Law prohibits self-referrals for designated health services billed to Medicare/Medicaid unless a specific statutory or regulatory exception applies.
Question 2: A credentialing specialist discovers that a practitioner failed to disclose a malpractice settlement on their application. Under most state laws, this constitutes:
- A minor administrative deficiency correctable by addendum
- Material misrepresentation, which is grounds for denial or termination (Correct answer)
- An NPDB reportable event that must be filed within 15 days
- A HIPAA violation requiring breach notification to the practitioner
Correct answer: Material misrepresentation, which is grounds for denial or termination
Intentional or negligent omission of required information on a credentialing application constitutes material misrepresentation and is grounds for denial, revocation, or termination of privileges under most state statutes and bylaws.
Question 3: Which federal regulation at 42 CFR Part 2 specifically restricts the disclosure of patient records related to substance abuse treatment?
- HIPAA Privacy Rule
- Confidentiality of Substance Use Disorder Patient Records (Part 2) (Correct answer)
- The Rehabilitation Act of 1973
- The Mental Health Parity and Addiction Equity Act
Correct answer: Confidentiality of Substance Use Disorder Patient Records (Part 2)
42 CFR Part 2 imposes stricter confidentiality requirements on substance use disorder treatment records than standard HIPAA protections, requiring patient consent for most disclosures.
Question 4: When a hospital's medical staff bylaws conflict with state law regarding credentialing procedures, which generally takes precedence?
- The medical staff bylaws, because they are contracts between the hospital and practitioners
- State law, because bylaws cannot require less than what law mandates (Correct answer)
- Federal CMS regulations, which supersede both bylaws and state law
- Accreditation standards, which carry the force of law for accredited institutions
Correct answer: State law, because bylaws cannot require less than what law mandates
State law sets the minimum floor for credentialing procedures; medical staff bylaws may provide additional protections but cannot reduce rights granted by statute.
Question 5: The False Claims Act allows private individuals to file lawsuits on behalf of the government against entities committing Medicare/Medicaid fraud. These individuals are known as:
- Relators (qui tam plaintiffs) (Correct answer)
- Whistleblower designees
- Federal compliance monitors
- Protected class petitioners
Correct answer: Relators (qui tam plaintiffs)
Under the False Claims Act's qui tam provisions, private individuals (relators) can file suit on the government's behalf and receive a portion of any recovery.
Question 6: A practitioner whose privileges are suspended for more than 30 days due to professional competence or conduct must be reported to the NPDB by:
- The state licensing board only
- The hospital or health plan that took the action (Correct answer)
- The practitioner themselves within 10 business days
- The malpractice carrier that insures the practitioner
Correct answer: The hospital or health plan that took the action
Hospitals and health plans must report to the NPDB any professional review action that adversely affects a practitioner's clinical privileges for more than 30 days.
Question 7: Which principle requires that practitioners facing adverse credentialing actions receive notice of the charges, an opportunity to be heard, and a written decision with findings?
- Res ipsa loquitur
- Due process (Correct answer)
- Promissory estoppel
- Collateral estoppel
Correct answer: Due process
Due process (both constitutional and as codified in HCQIA) requires that practitioners subject to adverse actions receive adequate notice, a fair hearing, and a written decision explaining the outcome.
CPCS Regulatory Requirements and Law 3
The Stark Law (42 U.S.C. §1395nn) primarily prohibits physician self-referrals for designated health services unless: