CPCS Exam 2023 Questions and Answers Rated A+

CPCS Exam 2023 Questions and Answers Rated A+ TJC (The Joint Commission) Definition of Credentialing The process of obtaining, verifying, and assessing the qualifications of a health care practitioner who seeks to provide patient care services in or for a hospital. NCQA (National Committee for Quality Assurance) definition of credentialing process by which an organization reviews and evaluates qualifications of licensed independent practitioners to provide services to its members. Should you use the same credentialing process for each applicant? YES - to ensure fairness and consistency of credentialing and to reduce the opportunity of charges if discrimination if there is a negative outcome Reasons for Credentialing Patient Safety, Risk Management concerns, and Required by Accrediting and Regulatory Agencies CoPs (abbrv.) Medicare Conditions of Participation What is CoPs? (medicare conditions of participation) Contained in the Code of Federal Regulations, are intended to protect patient health and safety to ensure quality of care for hospitalized patients. Why get Accredited? Accreditation assists organizations in monitoring and improving quality of care. Organizations that are accredited are a "deemed status" meaning they meet the Centers for Medicare ad Medicaids requirements for participation. Hospital Accrediting Bodies: The Joint Commission (TJC), American Osteopathic Association Health Facilities Accreditation Program (AO-HFAP), Det Norske Veritas Healthcare, Inc (DNV), National Integrated Accreditation for Healthcare Organizations (NIAHO) Managed Care Organization (MCO) Accrediting Bodies: National Committee for Quality Assurance (NCQA) Utilization Review Accreditation Commission (URAC) Ambulatory Accrediting Body: Accreditation Association for Ambulatory Health Care (AAAHC) Release of Liability - Statement that includes immunity to those who respond in good faith to requests for information PSV (abbrv.) Primary Source Verification - Original Source of Information. To recognize, investigate, and validate discrepancies and adverse information obtained from the application, primary source verifications, or other sources to ensure that review and approval bodies have the info needed to make informed credentialing decisions. NPDB (abbrv) National Practitioner Data Bank - Entity that was established through the Health Care Quality Improvement Act of 1986 to restrict the ability of incompetent physicians and other health providers to move from state to state without disclosure or discovery of previous medical malpractice payments and adverse action history. FSMB (abbrv.) Federation of State Medical Boards - nonprofit organization represents 70 medical and osteopathic boards of the United States. AMA (abbrv.) American Medical Association - Physicians master file AOA (abbrv.) American Osteopathic Association ECFMG (abbrv.) Education Commission for Foreign Graduates OIG (abbrv.) Office of Inspector General - exclusions from federal programs such as Medicare/Medicaid. Acceptable PSV (primary source verification): NPDB, FSMB, AMA, CIN-BAD (chiro), AOA, CSA, ECFMG, OIG and US General Services Administration. CSA (abbrv.) Controlled Substances Act - registration database DEA records AAAHC- Accreditation Association for Ambulatory Health Care - if wants to use a CVO - what must happen? Must perform an assessment of capability and quality of the CVO's work if not accredited by a governing body Per TJC, A nurse functioning independently and providing medical level of care must: Be granted delineated clinical privileges Per TJC, the governing body delegates the responsibility of credentialing recredentialing and privileges to? The Medical Staff Per TJC, Hospital standards require Medical Staff Bylaws to include: A mechanism for selection and removal of officers Medical liability insurance should be held in what limits? As specified in Bylaws and Board of Directors HFAP require three medical staff committees. What are the three? Med Exec, Utilization of Osteopathic Methods and Utilization Review Committee. HFAP (abbrv.) American Osteopathic Association Health Facilities Accreditation Program HFAP - when confirming malpractice coverage, the organization must: Have evidence of professional liability insurance, which includes certificate showing amounts of coverage. NCQA (abbrv.) (National Committee for Quality Assurance) NCQA (National Committee for Quality Assurance) - what PSV is required prior to provisional credentialing? Licensure, 5 years malpractice history or NPDB NCQA (National Committee for Quality Assurance) - If an organization discovers sanction information, complaint or adverse events regarding a practitioner? Determine if there's evidence of poor quality that can affect the health and safety of its members. NCQA (National Committee for Quality Assurance) - acceptable PSV for Medicare/Medicaid sanctions activity against Physicians? Federation of State Medical Boards Hospitals- Who has the authority to approve or disapprove the bylaws suggested by the Medical Staff per CMS guidelines? Governing Body What is a MCO (manage care organization) ? Commercial, 3rd party payers, healthcare networks and health plans. Physicians must be accepted to a Provider Panel - Required Credentials Committee approval only (NO GOVERNING BODY for approvals) NCQA & URAC are the accrediting bodies for an MCO. The Governing Body has the ultimate final authority and responsibility for oversight and delivery of care to what accreditation bodies? TJC, DNV, HFAP, AAAHC CMS (abbrv.) Centers for Medicare Services - part of the Dept of Health and Human Services. Oversees federal healthcare programs including meaningful use of incentive programs for health info technology. Compliance definition - Participate in the development implementation, and ongoing assessment of bylaws, rules and regulations, policies and procedures to ensure continuous compliance with accreditation and regulatory standards. DEA (abbrv) Federal Drug Enforcement Agency ACGME (abbrv) Accreditation Council for Graduate Medical Education Privileging definition - Process by which the specific scope of content of patient care services are authorized for a healthcare practitioner by an organization, based on evaluative of the individuals credentials and performance. "complete application" one in which the application itself is not only complete, but all PSV and information required by the medical staff bylaws, state and federal law, and accreditation requirements is completed. Due Process definition - Course of formal proceedings carried out regularly, fairly, and in accordance with established rules and regulations. Appeal definition - Formal request by a practitioner to request reconsideration of an adverse action. Hearing definition - formal proceeding at which evidence and arguments are presented on the matter to a person or body having decision making authority. peer review A review by people with similar training, background or credentials. The process by which a professional review body considers whether a practitioners clinical privileges or membership in a professional society will be adversely affected by a physicians competence or professional conduct. May include cognitive, technical and/or interpersonal skills. FPPE (abbrv.) Focused Practitioner Performance Evaluation OPPE (abbrv.) Ongoing Professional Practice Evaluation QAPI (abbrv.) Quality Assessment Performance Improvement HIPAA (abbrv.) Health Insurance Portability and Accountability Act Delegation definition - When an organization and entity complete a mutual agreement allowing the entity to complete specific credentialing functions. HCQIA (abbrv.) Health Care Quality Improvement Act - provides qualified immunity from the anti-trust liability arising out of peer activities that are conducted in good faith. Robert's Rules of Order A standard of running meetings effectively and efficiently, based on the procedures used in the British parliament. The principles included in the handbook are applicable to any decision-making organization, from Congress to community club committees. The handbook sets the guidelines for such issues as leading debates; recognizing speakers; defining the role of the chair and other officers; proposing, seconding, and voting on motions; and writing and amending constitutions and bylaws. Parliamentary Procedure. Patrick vs. Burgett Violation of Anti-Trust laws conducted by Anti-Peer Review; anti-competitive peer review. Johnson vs. Misericordia Community Hospital Negligent Credentialing- failure to verify initial hospital affiliations. the hospital did not apply its own credentialing rules, and therefore, did not follow its own standard of care in determining the qualifications of physicians practicing at the facility. McClellan vs. Health Maintenance Organization of Pennsylvania MCO liable for provider's actions - duty to select and monitor providers, negligent credentialing, ostensible agency. Hongsathavij vs. Queen of the Angels Hollywood Presbyterian Hospital Governing body is ultimate authority. Physician taken off back-up for failing to accept a patient. Oskooi vs. Fountain Valley Regional Hospital and Health Center, Failure to disclose - physicians did not disclose all prior hospital affiliations on application. Miller vs. Eisenhower Medical Center Disruptive behavior must be related to patient care. Denial of application based on inability to work well with others; no quality issues. Boyd vs. Albert Einstein Medical Center Ostensible agency; MCO liable for practitioner's action. IPA - type HMO advertised as providing medical care held liable for member MD's negligence CVO Credentialing Verification Organization. Independent org that performs primarily verification of a professional providers's credentials. Who/What Influences the credentialing process - contracts, accreditation standards, policies & procedures, federal/state law & regulations CVO - credentialing verification organization External Criteria for Credentialing/Privileging Set by forces outside the organization by accrediting bodies, federal regulations, etc Internal Criteria for Credentialing/Privileging Set by Hospitals, medical staff or MEC - board certifications, geographic distance, application fee's, etc AAAHC credentialing process = 3 phase process - independent process Does a MCO (managed care organization) grant privileges? No, MCO is membership only