NCCO Exam 3 – Questions with Detailed and Verified ANSWERs (100% Correct, Graded A+)

1. What is the primary goal of credentialing in healthcare? A) To increase hospital revenue B) To ensure that healthcare providers are qualified and competent to deliver care C) To reduce the number of malpractice lawsuits D) To streamline the billing process ANSWER: B) To ensure that healthcare providers are qualified and competent to deliver care. Credentialing is a vetting process to verify the qualifications, experience, and professional standing of a provider, thereby protecting patients. 2. The process of collecting and verifying a provider's professional qualifications is known as: A) Privileging B) Credentialing C) Enrollment D) Accreditation ANSWER: B) Credentialing. This is the specific term for the verification of credentials like education, training, licenses, and work history. 3. What is the purpose of privileging? A) To assign a provider to a specific department B) To determine the specific procedures and treatments a provider is permitted to perform within a facility C) To verify a provider's identity D) To set a provider's salary ANSWER: B) To determine the specific procedures and treatments a provider is permitted to perform within a facility. Privileging is facility-specific and based on the provider's verified credentials and demonstrated competence. 4. Which of the following is a primary source verification? A) Receiving a copy of a medical license from the provider B) Checking the state medical board's website directly to confirm license status C) Reviewing the provider's CV D) Contacting a reference provided by the provider ANSWER: B) Checking the state medical board's website directly to confirm license status. Primary source verification means obtaining information directly from the original source (e.g., the medical board, the medical school). 5. The National Practitioner Data Bank (NPDB) is primarily used to: A) Check a provider's credit history B) Report and query information on medical malpractice payments and adverse actions C) Verify a provider's immigration status D) Find a provider's home address ANSWER: B) Report and query information on medical malpractice payments and adverse actions. The NPDB is a critical tool for identifying providers with a history of disciplinary or malpractice issues. 6. What is the typical timeframe for the initial credentialing process from application to committee decision? A) 1-2 weeks B) 30-60 days C) 6-12 months D) 24 hours ANSWER: B) 30-60 days. This is a standard timeframe, allowing for the collection and verification of information from various primary sources, which can be time-consuming. 7. Which organization sets standards for healthcare quality and safety that often drive credentialing requirements? A) The Joint Commission (TJC) B) The Internal Revenue Service (IRS) C) The Department of Motor Vehicles (DMV) D) The Social Security Administration (SSA) ANSWER: A) The Joint Commission (TJC). TJC accreditation standards heavily influence the policies and procedures for medical staff credentialing and privileging. 8. A "Focused Professional Practice Evaluation (FPPE)" is triggered when: A) A provider renews their privileges B) A new provider is initially granted privileges or when a provider's performance indicates a need for monitoring C) A provider requests a vacation D) The hospital undergoes a financial audit ANSWER: B) A new provider is initially granted privileges or when a provider's performance indicates a need for monitoring. FPPE is a time-limited period of intensive evaluation. 9. "Ongoing Professional Practice Evaluation (OPPE)" is best described as: A) A one-time evaluation at hire B) A continuous process of monitoring a provider's clinical performance and competence C) An evaluation performed only when a patient complaint is filed D) A financial performance review ANSWER: B) A continuous process of monitoring a provider's clinical performance and competence. OPPE is a routine, data-driven process that feeds into the re-privileging decision. 10. Which document is essential for a provider to begin the credentialing process? A) A completed and signed application B) A copy of their high school diploma C) A list of personal friends D) A photograph of their office ANSWER: A) A completed and signed application. The application, along with an attestation by the provider, is the foundational document that authorizes the verification process. 11. The Health Care Quality Improvement Act (HCQIA) of 1986 was established to: A) Provide immunity for healthcare entities in peer review processes B) Regulate pharmaceutical prices C) Mandate electronic health records D) Standardize medical billing codes ANSWER: A) Provide immunity for healthcare entities in peer review processes. HCQIA encourages peer review by providing legal protection to those involved in good-faith professional review actions. 12. Verifying a provider's medical school graduation should be done through: A) The provider's transcript B) The American Medical Association (AMA) Masterfile or the medical school directly C) A letter from a colleague D) The state medical board ANSWER: B) The American Medical Association (AMA) Masterfile or the medical school directly. These are considered primary sources for medical education verification. 13. What is the purpose of a "query" to the NPDB? A) To report a new provider B) To request information about a provider's malpractice history and adverse actions C) To update a provider's profile D) To file a complaint against an insurance company ANSWER: B) To request information about a provider's malpractice history and adverse actions. Entities must query the NPDB during initial credentialing and every two years thereafter. 14. A "360-degree review" for credentialing might include feedback from: A) Peers, patients, and nursing staff B) Only the department chair C) Only the provider themselves D) Insurance companies ANSWER: A) Peers, patients, and nursing staff. This provides a comprehensive view of the provider's professional performance and interpersonal skills. 15. Re-credentialing typically occurs on what kind of cycle? A) Every 5 years B) Every 10 years C) Every 24 months D) Annually ANSWER: C) Every 24 months. A two-year cycle is standard for re-credentialing and re-privileging in most healthcare organizations. 16. What is a "sanction" check? A) A review of a provider's criminal background B) A verification to see if a provider has been excluded from participating in federal healthcare programs C) A check of their driving record D) A review of their credit score ANSWER: B) A verification to see if a provider has been excluded from participating in federal healthcare programs. This is done using the OIG LEIE and SAM.gov databases. 17. The Office of Inspector General's List of Excluded Individuals/Entities (OIG LEIE) is crucial for credentialing because it: A) Lists all licensed physicians in the U.S. B) Identifies providers who are not allowed to receive payment from Medicare, Medicaid, and other federal programs C) Provides a directory of medical specialties D) Shows the average cost of medical procedures ANSWER: B) Identifies providers who are not allowed to receive payment from Medicare, Medicaid, and other federal programs. Employing or contracting with an excluded individual can lead to severe penalties. 18. Which committee is ultimately responsible for recommending a provider for medical staff appointment and privileges? A) The Finance Committee B) The Medical Executive Committee (MEC) C) The Housekeeping Committee D) The Public Relations Committee ANSWER: B) The Medical Executive Committee (MEC). The MEC reviews the completed credentialing file and makes a recommendation to the Governing Body. 19. The "Governing Body" (e.g., Board of Directors) of a hospital has the final authority to: A) Perform the primary source verification B) Approve or deny medical staff appointments and privileges C) Dictate a provider's daily schedule D) Set individual patient care plans ANSWER: B) Approve or deny medical staff appointments and privileges. The MEC recommends, but the Governing Body has the ultimate legal responsibility. 20. A "Proctoring" process is often part of which type of evaluation? A) OPPE B) FPPE C) Billing Audit D) Financial Review ANSWER: B) FPPE. Proctoring, where a peer directly observes a procedure, is a common component of a Focused Professional Practice Evaluation. 21. What does "Delineation of Privileges" refer to? A) The list of specific services and procedures a provider is authorized to perform B) The geographic area a provider serves C) The outline of a hospital's budget D) The description of a patient's diagnosis ANSWER: A) The list of specific services and procedures a provider is authorized to perform. This form is specific to each provider's qualifications and specialty. 22. The "Credentials Verification Organization (CVO)" is an entity that: A) Provides medical treatment to patients B) Manages a hospital's finances C) Centralizes the credentialing process for multiple healthcare entities D) Sells medical equipment ANSWER: C) Centralizes the credentialing process for multiple healthcare entities. Using a CVO can improve efficiency and standardization (e.g., NCQA-certified CVOs). 23. Which of the following is a "core privilege" for a specialty? A) A privilege that requires additional documentation B) A privilege that is granted to all members of that specialty who meet basic criteria C) A privilege that is only for research purposes D) A privilege that is never used ANSWER: B) A privilege that is granted to all members of that specialty who meet basic criteria. Core privileges streamline the privileging process for common procedures within a specialty. 24. What is the main purpose of a "peer reference"? A) To verify the provider's address B) To obtain an evaluation of the provider's clinical skills, judgment, and professional conduct from a colleague C) To check the provider's credit history D) To confirm the provider's age ANSWER: B) To obtain an evaluation of the provider's clinical skills, judgment, and professional conduct from a colleague. This provides insight into the provider's real-world performance. 25. A "temporary privilege" may be granted under which circumstance? A) While waiting for the full credentialing process to be completed for a new applicant B) For a provider who has been sanctioned C) For a provider whose license has expired D) Without any application on file ANSWER: A) While waiting for the full credentialing process to be completed for a new applicant. This is strictly regulated and requires that a complete application has been received and there is no negative information. 26. The National Committee for Quality Assurance (NCQA) is known for: A) Accrediting managed care organizations and certifying CVOs B) Licensing physicians C) Setting medical school curricula D) Regulating hospital food services ANSWER: A) Accrediting managed care organizations and certifying CVOs. NCQA standards are a benchmark for credentialing quality. 27. What is a "closed claim" review? A) A review of malpractice cases that have been settled or adjudicated B) A review of open patient accounts C) A review of a hospital's closed wings D) A review of a provider's closed office hours ANSWER: A) A review of malpractice cases that have been settled or adjudicated. This can provide valuable information about a provider's practice patterns and potential risks. 28. The "Two-Year Rule" in credentialing typically refers to the requirement to: A) Query the NPDB at least every two years B) Fire a provider after two years C) Change a provider's specialty every two years D) Require a new physical exam every two years ANSWER: A) Query the NPDB at least every two years. This is a federal requirement for continuous monitoring. 29. What information is found in the Federation of State Medical Boards (FSMB) database? A) A provider's disciplinary history with state medical boards B) A provider's favorite medical journals C) A list of all hospitals in a state D) A provider's billing rates ANSWER: A) A provider's disciplinary history with state medical boards. This is a key primary source for licensure actions. 30. A "clean" credentialing file is one that: A) Has no coffee stains on it B) Has all required primary source verifications completed with no discrepancies or adverse information C) Contains only the application D) Has not been reviewed by the MEC ANSWER: B) Has all required primary source verifications completed with no discrepancies or adverse information. It is a file that is complete and ready for committee review without flags. 31. What is the primary purpose of a "self-query" to the NPDB? A) For a provider to see what information is being reported about them B) For a hospital to report a provider anonymously C) For an insurance company to deny a claim D) For a patient to file a complaint ANSWER: A) For a provider to see what information is being reported about them. Providers are encouraged to self-query periodically to ensure the accuracy of their data. 32. Which of the following would likely trigger an FPPE? A) A provider consistently meeting all OPPE criteria B) A significant increase in patient complaints or adverse outcomes C) A provider receiving an award D) A change in the hospital's name ANSWER: B) A significant increase in patient complaints or adverse outcomes. FPPE is designed to investigate and address potential performance issues. 33. The "4 A's" of a proper query to the NPDB are: A) Applicant, Agency, Action, Amount B) Who, What, When, Where C) Name, Date of Birth, Social Security Number, Profession D) Address, Age, Attitude, Aptitude ANSWER: C) Name, Date of Birth, Social Security Number, Profession. These are the essential data elements required to accurately identify a provider in the NPDB.