CPMSM ULTIMATE STUDY SET WITH
COMPLETE SOLUTIONS
NPDB - ANSWER-National Practitioner Databank
NPDB Contains: (what type of info) - ANSWER-- adverse licensure
- clinical privilege actions
- membership actions (professional/society)
- paid malpractice judgements
- exclusions from Medicare/Medicaid
- actions by US DEA
What must Hospitals and Other Health Care Entities report on for Physicians & Dentists
(3 things), and how quickly must it be reported? - ANSWER-- Professional review
actions based on competence, conduct, affecting privs >30 days
- voluntary surrender/restriction of privs
- to avoid investigation
Must be submitted to NPDB and State licensing board within 15 days of action
Who are entities that MUST report Physicians & Dentists to NPDB: (5 entities) -
ANSWER-- Medical malpractice payers
- State licensing board
- Hospitals and other Health Care Entity
- Professional society
- HHS OIG
Who are entities that MUST report Other Healthcare Practitioners to NPDB: (4 entities) -
ANSWER-- Medical malpractice payers
- Hospitals and other Health Care Entity (optional)
- Professional society (optional)
- HHS OIG
Per Federal Law, NPDB info must be available to: (6) - ANSWER-- hospitals and
healthcare entities
- professional societies
- state licensing auth
- healthcare practitioner (self-query)
- researchers (statistics only)
- plaintiff attorneys (limited circumstance)
Section 1921 of Social Security Act
- what did it create?
,- Why was it created?
- What does it do? - ANSWER-Medicare & Medicaid Patient and Program Protection
Act
To protect beneficiaries from fraud and abuse
Expanded licensure and actions taken against all licensed healthcare practitioners
Continuous Query was previously referred to as... - ANSWER-Previously - Proactive
Disclosure Service (PDS)
Continuous Query is accepted by which 3 accrediting agencies? - ANSWER-Accepted
by TJC, CMS, NCQA
When was the NPDB created?
Who was NPDB created by? - ANSWER--1986
-Established by Congress in
What is the purpose of the NPDB? - ANSWER-Tool that prevents practitioners from
moving state to state without disclosure or discovery of previous damaging
performance. Federal regulations authorize eligible entities to report to and/or query the
NPDB.
When did HIPDB and NPDB merge? - ANSWER-2013
What is the NPDB Public Use Data File? - ANSWER-Provides data to the public for
statistical reporting and analysis; no specific info is divulged about the practitioners or
reporting entities. Updated 4x per year
How quickly should an event be reported to the NPDB? - ANSWER-Within 30 days of
the event
Is an event reportable to the NPDB if privileges are affected for 30 days or less? -
ANSWER-No
Who maintains the NPDB? - ANSWER-Health Resources and Services Administration
(HRSA)
What is the Disclosure Penalty for NPDB? - ANSWER-Information on the NPDB is
confidential. Fines up to $10k. Up to $15k for false information
What is HIPDB? - ANSWER-Healthcare Integrity and Protection Data Base; created in
1996 by HIPAA to reduce healthcare fraud and abuse
Relationship Hospital and Medical Staff - ANSWER-● Can be a complex interdependent
relationship
,● Has changed because of ambulatory surgery centers
● Most physicians on the medical staff are not employees although that number is
growing
● The ability to work in the hospital most resembles a limited "license" granted to the
physician to practice in the hospital under a given set of rules called the Medical
Bylaws.
Medical Staff Bylaws - ANSWER-1. Establish the rights and responsibilities of the
medical staff members and the governing body (hospital)
2. Provide the governance structure of the medical staff
Bylaws must... - ANSWER-○ Be approved by the governing body
○ Statement of duties and privileges of category medical staff
○ Organization
○ Qualifications
○ Admission H and P requirements
○ Updated examination after admission
Economic Credentialing - ANSWER-● Generally upheld by courts
● The practice of conditioning a physician's appointment or reappointment to the
medical staff on the economic impact of the physician.
○ Utilization of the facilities
○ Number of other physicians in the same specialty
○ Availability of beds
○ Other hospitals the physician has privileges at and the extend to which they compete
Exclusive Contracts - ANSWER-● Could call into question anti-competitive behavior
● Usually with pathologists, radiologists, anesthesiologists
○ Improve efficiency
○ Standardize
○ Secure availability of needed services
○ Improve quality of care
Board Certification - ANSWER-● Can the Hospital base its decision on privileging solely
on the specialty board certification
● There is conflicting authority in the law
● Medicare COP infer that other factors should also be taken into consideration but that
"after analysis of all the criteria, if all criteria are met except for board certification, the
hospital has the discretion to decide not to select that individual to the medical staff"
Geographic Proximity Requirements - ANSWER-● How far do you live from the hospital
● Consider the size of the local market
● Consider response time to take care of patients
● Should they apply equally or not given the acuity with which patients must be seen at
the ED
● Is it being used to keep physicians from competing: antitrust concerns
, Number of Admissions - ANSWER-● The hospital is generally allowed to base its
reappointment to the medical staff on the number of contacts the physician has with the
patients that the hospital serves. This can be admissions or procedures done
● Claim is that the physician cannot be adequately evaluated related to competence if
he has not performed a requisite number of cases
On-Call Coverage Issues - ANSWER-● EMTALA requires that hospitals maintain an on
call list of physicians who can stabilize patients who present to ED
● Obligation for call is generally found in the bylaws
● Call can entail uncompensated care and increased malpractice risk
● Compensation for call
Integration of Hospital and Physician Groups - ANSWER-● Integrate: avoid some AKA
and Stark considerations, avoid administrative burdens, cost efficiencies, better
coordination of care and improved quality and lower cost
● Employee/physicians are members of the medical staff and employees
● All rules applicable to employees apply and all rules applicable to medical staff apply
● Hospital is responsible for negligence of physician not just negligent credentialing
Statutory, Regulatory and Accreditation - ANSWER-1. Medicare Conditions of
Participation (COP)
2. Accreditation Requirements
3. Health Care Quality Improvement Act of 1986(HCQIA)
4. The Americans with Disabilities Act of 1990 (ADA)
5. State Licensure Laws
Medicare COPs - ANSWER-● These are standards that all hospitals must achieve in
order to receive reimbursement under Medicare
● Requirements that there be an organized medical staff operating under written bylaws
and responsible to the governing body of the hospital
● Examples of COPs affecting the medical staff
○ Examine the credentials of candidates
○ Ensure maintenance of competence with periodic appraisals
○ Must adopt and enforce bylaws
Accreditation Requirements - ANSWER-Medicare accepts the accreditation of following
to satisfy CMS requirements:
○ Joint Commission
○ DNV
○ Center for Improvement in Healthcare Quality
○ American Osteopathic Association's Healthcare Facilities Accreditation Program
Three Parts of HCQIA - ANSWER-1. Provisions relating to immunity from damages for
those involved in professional review activities
COMPLETE SOLUTIONS
NPDB - ANSWER-National Practitioner Databank
NPDB Contains: (what type of info) - ANSWER-- adverse licensure
- clinical privilege actions
- membership actions (professional/society)
- paid malpractice judgements
- exclusions from Medicare/Medicaid
- actions by US DEA
What must Hospitals and Other Health Care Entities report on for Physicians & Dentists
(3 things), and how quickly must it be reported? - ANSWER-- Professional review
actions based on competence, conduct, affecting privs >30 days
- voluntary surrender/restriction of privs
- to avoid investigation
Must be submitted to NPDB and State licensing board within 15 days of action
Who are entities that MUST report Physicians & Dentists to NPDB: (5 entities) -
ANSWER-- Medical malpractice payers
- State licensing board
- Hospitals and other Health Care Entity
- Professional society
- HHS OIG
Who are entities that MUST report Other Healthcare Practitioners to NPDB: (4 entities) -
ANSWER-- Medical malpractice payers
- Hospitals and other Health Care Entity (optional)
- Professional society (optional)
- HHS OIG
Per Federal Law, NPDB info must be available to: (6) - ANSWER-- hospitals and
healthcare entities
- professional societies
- state licensing auth
- healthcare practitioner (self-query)
- researchers (statistics only)
- plaintiff attorneys (limited circumstance)
Section 1921 of Social Security Act
- what did it create?
,- Why was it created?
- What does it do? - ANSWER-Medicare & Medicaid Patient and Program Protection
Act
To protect beneficiaries from fraud and abuse
Expanded licensure and actions taken against all licensed healthcare practitioners
Continuous Query was previously referred to as... - ANSWER-Previously - Proactive
Disclosure Service (PDS)
Continuous Query is accepted by which 3 accrediting agencies? - ANSWER-Accepted
by TJC, CMS, NCQA
When was the NPDB created?
Who was NPDB created by? - ANSWER--1986
-Established by Congress in
What is the purpose of the NPDB? - ANSWER-Tool that prevents practitioners from
moving state to state without disclosure or discovery of previous damaging
performance. Federal regulations authorize eligible entities to report to and/or query the
NPDB.
When did HIPDB and NPDB merge? - ANSWER-2013
What is the NPDB Public Use Data File? - ANSWER-Provides data to the public for
statistical reporting and analysis; no specific info is divulged about the practitioners or
reporting entities. Updated 4x per year
How quickly should an event be reported to the NPDB? - ANSWER-Within 30 days of
the event
Is an event reportable to the NPDB if privileges are affected for 30 days or less? -
ANSWER-No
Who maintains the NPDB? - ANSWER-Health Resources and Services Administration
(HRSA)
What is the Disclosure Penalty for NPDB? - ANSWER-Information on the NPDB is
confidential. Fines up to $10k. Up to $15k for false information
What is HIPDB? - ANSWER-Healthcare Integrity and Protection Data Base; created in
1996 by HIPAA to reduce healthcare fraud and abuse
Relationship Hospital and Medical Staff - ANSWER-● Can be a complex interdependent
relationship
,● Has changed because of ambulatory surgery centers
● Most physicians on the medical staff are not employees although that number is
growing
● The ability to work in the hospital most resembles a limited "license" granted to the
physician to practice in the hospital under a given set of rules called the Medical
Bylaws.
Medical Staff Bylaws - ANSWER-1. Establish the rights and responsibilities of the
medical staff members and the governing body (hospital)
2. Provide the governance structure of the medical staff
Bylaws must... - ANSWER-○ Be approved by the governing body
○ Statement of duties and privileges of category medical staff
○ Organization
○ Qualifications
○ Admission H and P requirements
○ Updated examination after admission
Economic Credentialing - ANSWER-● Generally upheld by courts
● The practice of conditioning a physician's appointment or reappointment to the
medical staff on the economic impact of the physician.
○ Utilization of the facilities
○ Number of other physicians in the same specialty
○ Availability of beds
○ Other hospitals the physician has privileges at and the extend to which they compete
Exclusive Contracts - ANSWER-● Could call into question anti-competitive behavior
● Usually with pathologists, radiologists, anesthesiologists
○ Improve efficiency
○ Standardize
○ Secure availability of needed services
○ Improve quality of care
Board Certification - ANSWER-● Can the Hospital base its decision on privileging solely
on the specialty board certification
● There is conflicting authority in the law
● Medicare COP infer that other factors should also be taken into consideration but that
"after analysis of all the criteria, if all criteria are met except for board certification, the
hospital has the discretion to decide not to select that individual to the medical staff"
Geographic Proximity Requirements - ANSWER-● How far do you live from the hospital
● Consider the size of the local market
● Consider response time to take care of patients
● Should they apply equally or not given the acuity with which patients must be seen at
the ED
● Is it being used to keep physicians from competing: antitrust concerns
, Number of Admissions - ANSWER-● The hospital is generally allowed to base its
reappointment to the medical staff on the number of contacts the physician has with the
patients that the hospital serves. This can be admissions or procedures done
● Claim is that the physician cannot be adequately evaluated related to competence if
he has not performed a requisite number of cases
On-Call Coverage Issues - ANSWER-● EMTALA requires that hospitals maintain an on
call list of physicians who can stabilize patients who present to ED
● Obligation for call is generally found in the bylaws
● Call can entail uncompensated care and increased malpractice risk
● Compensation for call
Integration of Hospital and Physician Groups - ANSWER-● Integrate: avoid some AKA
and Stark considerations, avoid administrative burdens, cost efficiencies, better
coordination of care and improved quality and lower cost
● Employee/physicians are members of the medical staff and employees
● All rules applicable to employees apply and all rules applicable to medical staff apply
● Hospital is responsible for negligence of physician not just negligent credentialing
Statutory, Regulatory and Accreditation - ANSWER-1. Medicare Conditions of
Participation (COP)
2. Accreditation Requirements
3. Health Care Quality Improvement Act of 1986(HCQIA)
4. The Americans with Disabilities Act of 1990 (ADA)
5. State Licensure Laws
Medicare COPs - ANSWER-● These are standards that all hospitals must achieve in
order to receive reimbursement under Medicare
● Requirements that there be an organized medical staff operating under written bylaws
and responsible to the governing body of the hospital
● Examples of COPs affecting the medical staff
○ Examine the credentials of candidates
○ Ensure maintenance of competence with periodic appraisals
○ Must adopt and enforce bylaws
Accreditation Requirements - ANSWER-Medicare accepts the accreditation of following
to satisfy CMS requirements:
○ Joint Commission
○ DNV
○ Center for Improvement in Healthcare Quality
○ American Osteopathic Association's Healthcare Facilities Accreditation Program
Three Parts of HCQIA - ANSWER-1. Provisions relating to immunity from damages for
those involved in professional review activities
