CPCS Regulatory Requirements and Law 5

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?

Accepted Answer

NCQA Credentialing Standards (CR 1)

Answer

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:

Accepted Answer

Had an anticompetitive effect on a relevant market and lacked a legitimate business justification

Answer

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?

Accepted Answer

A non-physician-owned corporation directly employing physicians and controlling their clinical decisions

Answer

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?

Accepted Answer

Individual practitioners and healthcare entities querying their own records

Answer

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?

Accepted Answer

Corporate negligence

Answer

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.

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS - Certified Provider Credentialing Specialist Practice Test

CPCS Regulatory Requirements and Law 5