CPCS Certified Provider Credentialing Specialist (2023/2024) Graded A

CPCS Certified Provider Credentialing Specialist (2023/2024) Graded A What elements should a peer recommendation include according to TJC? Patient Care, medical clinical knowledge, practice based learning, interpersonal and communication skills, system-based practice Peer recommendations according to NCQA There is no specific requirement for peer recommendations. The organization must designate a Credentialing Committee that uses a peer-review process to make recommendations regarding credentialing decisions. Peer recommendations according to HFAP. Must obtain at least one peer with the same professional credential as the applicant that includes a statement regarding the physician's physical and mental health in relation to privileges requested. Peer recommendations according to URAC. There is no specific requirement for peer recommendations other than that a peer group makes the final credentialing determinations. Peer recommendations according to AAAHC. Required for initial and reappointment. Practitioners Credentialed and Privileged through the Medical Staff - TJC All individuals who are permitted by law and the hospital to provide patient care independently in the hospital are required to be credentialed and privileged under the Medical Staff standards. Practitioners Credentialed and Privileged through the Medical Staff - NCQA Standards address credentialing, not privileging. Practitioners Credentialed and Privileged through the Medical Staff - HFAP Standards regarding medical staff composition are a direct quote of CMS. The governing body must ensure that any privileges granted to non-physician practitioners are in accordance with State law, regulations and scope of practice. Practitioners Credentialed and Privileged through the Medical Staff - URAC All practitioners listed in the directory and are providing covered healthcare services to consumers are credentialed. Practitioners Credentialed and Privileged through the Medical Staff - AAAHC At a minimum, physicians and dentists are credentialed and privileged. Board determines which other qualified professionals (AHPs) it wishes to allow on staff. Privileges according to TJC The hospital must have a clearly documented procedure for the processing of requests for initial granting, renewal or revision of privileges. This process must be approved by the medical staff. Privileges according to NCQA Verification of clinical privileges is not required. Privileges according to URAC Application includes hospital affiliations or privileges, if applicable. Privileges according to AAAHC Privileging includes determination of the clinical procedures and treatments to be offered to patients, determination of the qualifications (training and experience) required, and approving or modifying privileges in a non-arbitrary manner. Temporary Privileges/Provisional Credentialing - TJC The CEO or designee may grant temporary privileges upon recommendation of the president of the medical staff or designee. Temporary Privileges/Provisional Credentialing - NCQA Standards do not reference privileges, but they do have a process for Provisional Credentialing. Approval of Provisional Credentialing - NCQA If the file meets the organization's definition of a "clean file", the Medical Director can approve. Temporary Privileges/Provisional Credentialing - HFAP Bylaws provide for the granting of temporary privileges. Temporary Privileges/Provisional Credentialing - URAC The organization can grant "provisional" participation status for a limited time when justified by continuity or quality of care issues on approval of the senior clinical staff person. Temporary Privileges/Provisional Credentialing - AAAHC Temporary Privileges or Provisional Credentialing are not specifically addressed. Work History - TJC There is no specific requirement for verification of work history. Work History - NCQA Verification time limit: 365 calendar days; does not require PSV of work history. A minimum of five years of relevant work history must be obtained through the practitioner's application or CV. Work History - HFAP Verification of healthcare employment and work history is required. Applicants must provide clinical activity documentation and competency. Work History - URAC Not specifically addressed, but application must include hospital affiliations and privileges and history of loss or limitation of privileges or disciplinary activity. Work History - AAAHC On initial appointment, experience is reviewed for continuity and relevance with documentation of any interruptions. 30 days Adverse actions affecting clinical privileges for a period longer than how many days must be reported to the NPDB? 15 days Adverse actions affecting clinical privileges report should be submitted to the state and NPDB within how many days of the action? 30 days Within how many days of a licensure disciplinary action, based on reasons related to professional conduct, must the licensing board report to the NPDB? Special release developed by the MEC An organization has sent a request for information regarding a physician on staff who has exhibited behavioral issues at a facility. What release form should the facility obtain prior to releasing this information to the requesting organization? The organization must initially credential the practitioner before reinstatement. According to NCQA, if a practitioner terminates or is terminated from the contract or there is a break in service over 30 days, can the practitioner be reinstated without credentialing. DEA Schedule I High abuse potential, no medical use. DEA Schedule II High abuse potential with dependency liability DEA Schedule III Less abuse potential, moderate dependence DEA Schedule IV Less abuse potential, limited dependence DEA Schedule V Limited abuse potential NTIS Name an organization that can be queried to obtain a copy of a DEA. CMS Which agency requires a Medicare attestation? The originating site has evidence of an internal review. According to TJC rules on credentialing of telemedicine providers, the origination site can use credentialing and privileging information from the distant site if the distant site is TJC accredited, the provider is privileged at the distant site and_________________________? When the information provided is false and the person providing the information knew it was false. Individuals provide information to professional review bodies regarding the competence or conduct of a physician are protected from liability except when? Committee Chair When preparing for a committee meeting, who would the MSP most likely meet with to coordinate the agenda and meeting packet? Phillippines NPDB - Peer review protection does not apply where? Patrick v Burget, US Supreme Court 1988 Anti-competitive peer review let to the development of HCQIA. Garland Community v Rose Negligent credentialing. Plaintiff underwent cosmetic surgery with poor outcomes. Patient learned of other complaints against doctor and hospital therefore sued for negligent credentialing. Bell v Sharp Carbrillo Hospital, California 1989 Negligent credentialing. Hospital liable for failure to request data from another hospital regarding it's summary suspension of practitioner. Oskooi vs Fountain Valley Regional Health Center, California 1996 Failure to disclose. Ophthalmologist did not disclose all prior hospital affiliations on application. Matthews vs Lancaster General Hospital, Tennessee 1996 HCQIA. Burden on physician to prove bad faith peer review. Webman vs Little Company of Mary Hospital, California 1995 Duty to credential. Application denied when physician refused to authorize prior hospital to release information. Mahmoodian v United Hospital Center, West Virginia 1991 Disruptive behavior. Hospital revoked physicians privileges. McClellan v Health Maintenance Organization of Pennsylvania 1996 Managed care organization found liable for provider's actions due to negligent credentialing. Hongsathavig v Queen of Angels Hollywood Presbyterian, California 1998 Governing body has ultimate authority. Board overturned hearing committee recommendation to reinstate call panel membership. Harrell v Total Health Care The managed care organization in this case was not held liable for negligent credentialing because state law granted immunity to not-for-profit health plans. Robinson v Magovern, 1981 MD brought anti-trust suit against the hospital after his application was denied. Darling v Charleston Memorial Community Hospital, 1965 End of doctrine of charitable immunity; patient lost leg due to improper casting. Elam v college Park Hospital, 1982 Doctrine of corporate negligence. Medical records had information on many lawsuits against podiatrist. Gonzales v Nork & Mercy Hospital, 1968 Hospitals owe patients a duty of care. Laminectomy negligently performed. MD had history of unnecessary negligent surgeries. Miller v Eisenhower Medical Center Denial of application due to physician's inability to work with others, no quality of care issues identified. Rao v Auburn General, 1978 Personality may be considered. MD denied privileges after reports from other hospitals on termination/restriction of privileges. Boyd v Albert Einstein Hospital, 1988 Doctrine of ostensible agency. HMO found liable in patient's death. Chest perforation during biopsy, chest pain/MI six weeks later. New pathways What terminology references the new and revised elements of TJC accreditation and survey process? CAHPS What does NCQA call a core survey administered separately to commercially insurance Medicare and Medicaid populations? HEDIS A set of standardized measures used to compare health plans by NCQA. 2 years NCQA grants a CVO certification for a period of how long? 3 years, 1 year, denial What are the categories of possible NCQA accreditation? 10 days Organizations notified of a conditional accreditation decision have how many business days to request a re-examination of the survey findings?