CPCS Regulatory Requirements and Law 4 — Questions and Answers
Question 1: Under HIPAA, which of the following is a permissible use of a practitioner's credentialing information without explicit authorization?
- Sharing the practitioner's peer review findings with their personal attorney
- Disclosing credentialing status to another hospital for treatment or quality improvement purposes (Correct answer)
- Providing malpractice history to a news organization investigating the practitioner
- Selling credentialing records to a locum tenens staffing agency for marketing
Correct answer: Disclosing credentialing status to another hospital for treatment or quality improvement purposes
HIPAA permits disclosure of credentialing information to other covered entities for treatment, payment, and healthcare operations purposes, including quality assessment activities.
Question 2: The Medicare Conditions of Participation require that a hospital's medical staff bylaws be approved by the:
- State department of health
- Governing body (board of directors) of the hospital (Correct answer)
- CMS regional administrator
- Joint Commission accreditation committee
Correct answer: Governing body (board of directors) of the hospital
CMS Conditions of Participation (42 CFR §482.12) require that the hospital's governing body approve and be responsible for the medical staff bylaws and credentialing policies.
Question 3: An anti-kickback statute violation in the credentialing context could arise if privileges are granted in exchange for:
- A practitioner agreeing to treat a minimum number of uninsured patients
- A practitioner referring Medicare patients to the hospital's ancillary services (Correct answer)
- A practitioner volunteering to serve on hospital committees
- A practitioner maintaining board certification in their specialty
Correct answer: A practitioner referring Medicare patients to the hospital's ancillary services
Conditioning privilege grants on referral commitments could violate the Anti-Kickback Statute if federal healthcare program patients are involved, as it constitutes remuneration to induce referrals.
Question 4: Which law prohibits employment discrimination based on race, color, religion, sex, or national origin, and applies to credentialing decisions in qualifying healthcare organizations?
- Title VI of the Civil Rights Act of 1964
- Title VII of the Civil Rights Act of 1964 (Correct answer)
- Section 504 of the Rehabilitation Act
- The Age Discrimination in Employment Act
Correct answer: Title VII of the Civil Rights Act of 1964
Title VII of the Civil Rights Act of 1964 prohibits employment discrimination based on protected characteristics and applies to credentialing decisions in organizations with 15 or more employees.
Question 5: A credentialing organization that shares peer review information with another hospital during a credentialing inquiry is generally protected from liability under:
- The Freedom of Information Act
- State peer review confidentiality statutes (Correct answer)
- The Privacy Act of 1974
- ERISA preemption doctrine
Correct answer: State peer review confidentiality statutes
Most states have peer review confidentiality statutes that protect the sharing of quality assurance and credentialing information between healthcare entities from discovery and civil liability.
Question 6: Under the ADA, a hospital is required to credential a practitioner with a disability if the practitioner:
- Can perform the essential functions of the clinical privileges requested with or without reasonable accommodation (Correct answer)
- Provides a letter from their treating physician certifying fitness for duty
- Agrees to restrict their practice to non-procedural specialties
- Has completed a fitness-for-duty evaluation ordered by the hospital
Correct answer: Can perform the essential functions of the clinical privileges requested with or without reasonable accommodation
The ADA requires consideration of whether a practitioner can perform the essential functions of the requested privileges, with reasonable accommodation if needed, before making an adverse credentialing decision.
Question 7: Which provision of the Affordable Care Act most directly affected credentialing by requiring health plans to establish provider credentialing standards and uniform credentialing applications?
- Section 1001 (Patient Protections)
- Section 1311 (qualified health plan credentialing requirements) (Correct answer)
- Section 2704 (prohibition on preexisting condition exclusions)
- Section 3021 (Center for Medicare and Medicaid Innovation)
Correct answer: Section 1311 (qualified health plan credentialing requirements)
ACA Section 1311 required qualified health plans operating in exchanges to meet credentialing standards, including using uniform credentialing applications established by HHS.
CPCS Regulatory Requirements and Law 4
Under HIPAA, which of the following is a permissible use of a practitioner's credentialing information without explicit authorization?