CPMSM - Study Guide Material 2023

What are four models of HMOs? - Staff Model Group Model Network Model Independent Practice Association (IPA) What are the four types of committees? - Standing Ad hoc Task force Continuous quality improvement team How many medical staff members comprise a Bylaws Committee? - 5 At least five active medical staff How many medical staff members comprise a Credentials Committee? - 5 At least five active medical staff How many medical staff members must serve on an Infection Control Committee? - 3 At least three active medical staff How many medical staff members must serve on a Medical Records Committee? - 1 At least one active medical staff How often should the Medical Records committee meet? - At least quarterly How many medical staff members must serve on a Pharmacy & Therapeutics Committee? - 5 At least five active medical staff How often should the Pharmacy & Therapeutics committee meet? - At least quarterly How many medical staff members must serve on a Utilization Review Committee? - 1 At least one active medical staff How often should the Utilization Review Committee meet? - Every other month What is 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? - Credentialing What are the three reasons for credentialing? - Patient Safety Risk Management Required by agencies Which three accreditors have been granted "deemed status"? - TJC, HFAP, DNV Which two organizations offer accreditation for managed care organizations? - NCQA, URAC Who is the main accreditor for ambulatory care facilities? - AAAHC Physicians who are employees of a facility as hospitalists and who are not listed in the provider directory are not included in the scope of the credentialing standards with this accreditation? - URAC For which accreditation, do the following practitioners need *not* to be credentialed including: -exclusively in the inpatient setting caring for organization members only in the hospital setting -practice exclusively in free-standing setting for members directed to facility -pharmacists working for a PBM (pharmacy benefits management) organization for UM functions -locum tenens working less than 90 days -rental network practitioners providing out of area care - NCQA What are Medicare CoP's minimum criteria for appointment to the medical staff/granting of medical staff privileges? - CCJET character competence judgement experience training CMS regulations require that medical staff bylaws include what information pertaining to each category of the medical staff? - duties and privileges Do providers with refer and follow status have admitting privileges/ordering privileges within the hospital? - No For TJC, does "privileges" refer to duties and prerogatives of each category or the clinical privileges to provide care? - Duties and prerogatives Which accreditor requires an applicant to submit a statement that no health problems exist which could affect his or her ability to provide care? - TJC Which accreditor has *no* specific requirements for professional practice questions on the application or reapp? - DNV For Medicare deemed facilities, the delegation of credentialing agreement must include what clause? - Adhere to Medicare regulations How often must the delegate organization provide a report to Credentials for a URAC facility? - Annually What is the NCQA requirement for monitoring member complaints about providers? - Continually monitoring member complaints for all practitioner sites Performing a site visit within 60 days if a threshold was met What is the only NCQA-required reporting for delegated credentialing? - The names or files of practitioners or providers processed by the delegate What is the credentialing timeframe for URAC? - 6 months No credentialing application is submitted for initial review if it is signed and dated more than 180 days prior to credentialing committee review or if it contains primary or secondary source verification information collected more than six months prior to review. What are the two requirements for verification at reappointment for DNV? - Licensure Current Competence What is verification of a practitioner's credentials based upon evidence obtains by means other than direct contact with the issuing source of the credential? (e.g. copies of licenses/certifications or database queries) - Secondary Source What year was HIPAA established? - 1996 Which two entities can report to HIPDB? - Federal/state government agencies Health Plans Which agency was established to combat fraud and abuse in health insurance and health care delivery and to promote quality care by HIPAA? - HIPDB What year did reporting to HIPDB begin? - 1999 What is a national non-profit organization representing the 70+ medical and osteopathic boards? - FSMB