CPCS Regulatory Requirements and Law 5 — Questions and Answers
Question 1: When a managed care organization (MCO) delegates credentialing to a medical group, the MCO remains responsible for ensuring the delegated entity meets credentialing standards under which framework?
- URAC Provider Credentialing Standards
- NCQA Credentialing Standards (CR 1) (Correct answer)
- CMS Delegation of Authority Guidelines
- Joint Commission Medical Staff Standard MS.13
Correct answer: NCQA Credentialing Standards (CR 1)
NCQA Credentialing Standard CR 1 governs MCO delegation of credentialing functions and requires the MCO to maintain oversight accountability even when functions are delegated to a medical group.
Question 2: A practitioner claims that a hospital's denial of privileges constitutes an antitrust violation under the Sherman Act. To succeed, the practitioner must generally show that the denial:
- Was motivated by personal animosity from a competing physician
- Had an anticompetitive effect on a relevant market and lacked a legitimate business justification (Correct answer)
- Violated the hospital's own bylaws on any procedural ground
- Resulted in financial harm to the practitioner exceeding $75,000
Correct answer: Had an anticompetitive effect on a relevant market and lacked a legitimate business justification
To establish a Sherman Act antitrust claim, the practitioner must prove the denial had a substantial anticompetitive effect in a defined market and was not justified by legitimate quality or safety concerns.
Question 3: Under state corporate practice of medicine laws, which credentialing-related arrangement is most likely to be prohibited?
- A hospital credentialing practitioners employed by an independent physician group
- A non-physician-owned corporation directly employing physicians and controlling their clinical decisions (Correct answer)
- A health plan contracting with a credentialing verification organization (CVO)
- A medical group delegating primary source verification to an affiliated hospital
Correct answer: A non-physician-owned corporation directly employing physicians and controlling their clinical decisions
Corporate practice of medicine doctrine in many states prohibits non-physician entities from employing physicians in ways that allow lay control over clinical decision-making.
Question 4: The NPDB Self-Query allows which of the following to access their own NPDB records?
- Hospital credentialing committees reviewing a practitioner's file
- Individual practitioners and healthcare entities querying their own records (Correct answer)
- State licensing boards conducting random audits
- Malpractice insurance carriers underwriting new policies
Correct answer: Individual practitioners and healthcare entities querying their own records
The NPDB Self-Query program allows individual practitioners and healthcare entities to access their own NPDB records to verify accuracy before applying for privileges or licensure.
Question 5: Which legal doctrine holds that a hospital may be liable for negligent credentialing if it grants privileges to an incompetent practitioner who then harms a patient?
- Respondeat superior
- Corporate negligence (Correct answer)
- Vicarious liability
- Ostensible agency
Correct answer: Corporate negligence
The corporate negligence doctrine (established in Darling v. Charleston Community Memorial Hospital) holds hospitals directly liable for failing to properly credential and supervise their medical staff.
Question 6: A practitioner's clinical privileges automatically lapse when their medical license expires. This credentialing policy is an example of which legal mechanism?
- Summary suspension
- Automatic termination or lapse provision (Correct answer)
- Precautionary suspension
- Collegial intervention step
Correct answer: Automatic termination or lapse provision
Automatic termination or lapse provisions in medical staff bylaws provide that privileges cease immediately and automatically upon certain triggering events such as license expiration, without requiring a formal hearing.
Question 7: Which federal agency oversees the NPDB and has authority to impose civil monetary penalties on entities that fail to report required information?
- The Centers for Medicare and Medicaid Services (CMS)
- The Health Resources and Services Administration (HRSA) (Correct answer)
- The Office of Inspector General (OIG)
- The Agency for Healthcare Research and Quality (AHRQ)
Correct answer: The Health Resources and Services Administration (HRSA)
HRSA administers the NPDB and has authority to investigate violations and impose civil monetary penalties on entities that fail to report required adverse actions and malpractice payments.
CPCS Regulatory Requirements and Law 5
When a managed care organization (MCO) delegates credentialing to a medical group, the MCO remains responsible for ensuring the delegated entity meets credentialing standards under which framework?