1. How Much Do You Know About Regulatory Standards?
Terri Coburn, CPMSM, CPHQ, CPCS
Director of Medical Staff Services
Trident Health, Charleston, SC

2. Game Rules
Up to 10
questions
each are
possible
2 Lifelines

3. Absolutely No Cash Dollar Store Prizes New Knowledge
What are we playing for?
Absolutely No Cash Dollar Store Prizes New Knowledge

4. Which accreditor does not require reappointment to the month and day?1
Which accreditor does not require reappointment to the month and day?
A. TJC
B. CMS
C. URAC
D. HFAP

5. C. URAC

6. NCQA has a licensure verification time limit of _________ for MCO’s:2
A. 180 days
NCQA has a licensure verification time limit of _________ for MCO’s:
A. 180 days
B. 120 day
C. 150 days
D. 365 days

7. A. 180 days

8. CMS standards are known as Conditions of ___________.3
CMS standards are known as Conditions of ___________.
A. Precipitation
B. Preparation
C. Accreditation
D. Participation

9. D. Participation

10. 4
One outcome of the HCQIA was the establishment of national standards for:
A. Quality Committee
B. Fair Hearing
C. IRB
D. GME Programs

11. B. Fair Hearing

12. D. The applicant looks funny5
TJC does not allow incomplete applications be considered for expedited credentialing. What is another reason for ineligibility?
A. Limitation of
clinical privileges
B. Adverse
recommendation by MEC
C. Revocation of
licensure
D. The applicant looks funny

13. B. Adverse recommendation by MEC

14. 6
In Roberts Rules of Order, secondary motions are divided into privileged, subsidiary, incidental, and these motions:
A. Main
B. Recess
C. Fixed
D. Recall

15. D. Recall

16. 7
AAAHC requires the disclosure of what information that may interfere with the ability to provide high quality patient care?
A. Substance
abuse problems
B. Chemical dependency
problems
C. Lack of opiate use
D. Lack of DUI’s

17. B. Chemical dependency problems

18. 8
Which accrediting agency does not address due process for medical staff?
A. DNV
B. CMS
C. HFAP
D. NCQA

19. B. CMS

20. 9
Which accreditors do NOT have specific standards regarding malpractice coverage? TJC, CMS, and:
A. AAAHC
B. HFAP
C. NCQA
D. URAC

21. A. AAAHC

22. Which member is required for an IRB quorum?10
Which member is required for an IRB quorum?
A. Non-Scientific
B. Department Chairman
C. Scientific
D. Committee Chair

23. A. Non-Scientific

24. C. personal humanitarian1
HIPAA focuses on privacy and PHI:
A. personal health
information
B. professional health
information
C. personal humanitarian
information
D. an animal at the zoo

25. A. Personal health information

26. 2
The ___________ sets and enforces standards in physician continuing education
A. ACGME
B. CMS
C. ACCME
D. AAAHC

27. C. ACCME

28. 3
According to HFAP, _________ functions include monitoring of complaints.
A. Credentials
Committee
B. QAPI
C. MEC
D. Board of Trustees

29. B. QAPI

30. 4
Which accrediting agency requires a physician profile be used as part of credentialing?
A. TJC
B. NCQA
C. URAC
D. HFAP

31. D. HFAP

32. Which accreditor requires CME 5
Which accreditor requires CME
to be considered at reappointment of privileges?
A. AAAHC
B. NCQA
C. TJC
D. HFAP

33. C. TJC

34. C. Physician Assistants6
According to NCQA, DEA/CDS are not applicable to:
A. Medical doctors
B. Chiropractors
C. Physician Assistants
D. Nurse Midwives

35. B. Chiropractors

36. Another term for Residents and Interns is:7
Another term for Residents and Interns is:
A. Faculty
B. Hospitalists
C. House Staff
D. Ancillary Staff

37. C. House Staff

38. What is the frequency of DNV on-site surveys?8
What is the frequency of DNV on-site surveys?
A. One year
B. Two years
C. Three years
D. Only as needed

39. A. One year

40. 9
According to URAC, which person in the organization is responsible for oversight of the clinical aspects of the credentialing program?
A. CEO
B. Senior clinical
staff person
C. Medical Director
or designee
D. CNO

41. B. Senior clinical staff person

42. ERCP is performed by a: A. Cardiologist B. Otolaryngologist10
ERCP is performed by a:
A. Cardiologist
B. Otolaryngologist
C. Ophthalmologist
D. Gastroenterologist

43. D. Gastroenterologist

44. 1
Which accrediting agency does not require providers be notified of reappointment approvals?
A. NCQA
B. DNV
C. URAC
D. AAAHC

45. A. NCQA

46. 2
In what timeframe does URAC standards require credentialing decisions for initial appointment be communicated to the provider?
A. 10 business days
B. 10 calendar days
C. 20 business days
D. 20 calendar days

47. A. 10 business days

48. TJC was previously known as:3
TJC was previously known as:
A. JCAHO
B. The Joint
C. JACHO
D. Inglorious Bastards

49. A. JCAHO

50. Provisional status (NCQA) cannot last for more than how many days?4
Provisional status (NCQA) cannot last for more than how many days?
A. 30 calendar
B. 30 business
C. 60 calendar
D. 60 business

51. C. 60 calendar

52. Which accreditor requires reappointment at least every 36 months?5
Which accreditor requires reappointment at least every 36 months?
A. CMS
B. TJC
C. NCQA
D. HFAP

53. C. NCQA

54. 6
According to HFAP, a recommendation will be made to the MEC within how many days of receipt of completed application?
A. 20 days
B. 30 days
C. 60 days
D. 120 days

55. C. 60 days

56. A. Funeral arrangements7
Advanced Directives include all of the following, except:
A. Funeral arrangements
B. Power of Attorney
C. DNR’s
D. Living Will

57. A. Funeral Arrangements

58. 8
TJC standards allow temporary privileges to be granted for no more than:
A. 30 Days
B. 60 Days
C. 90 Days
D. 120 Days

59. D. 120 Days

60. A. Parliamentary Inquiry9
In Roberts Rules of Order, this motion is raised to call attention to a violation of accepted rules and procedures of the assembly.
A. Parliamentary Inquiry
B. Request for
information
C. Request for
consideration
D. Point of order

61. D. Point of Order

62. NCQA standards require this committee:10
NCQA standards require this committee:
A. Credentialing
B. Utilization Review
C. Peer Review
D. MEC

63. A. Credentialing

64. 1
In NCQA delegated credentialing, a written delegation agreement must include reporting to the organization at least:
A. Monthly
B. Quarterly
C. Semi-annually
D. Annually

65. C. Semi-annually

66. D. Maxillofacial Surgeon2
Kyphoplasty or vertebroplasty are performed by all of the following, except:
A. Orthopedic Surgeon
B. Interventional
Radiologist
C. Neurosurgeon
D. Maxillofacial Surgeon

67. D. Maxillofacial Surgeon

68. The Federal “anti-dumping” law is also known as:3
The Federal “anti-dumping” law is also known as:
A. Brady Bill
B. EMTALA
C. Sherman Anti-Trust
Act
D. Healthcare Quality
Improvement Act

69. B. EMTALA

70. CVO is an acronym for: A. Credentials Verification Organization4
CVO is an acronym for:
A. Credentials
Verification Organization
B. Commission on
Verifications Office
C. Central Verification
Office
D. Chief Visionary Officer

71. A. Credentials Verification Organization

72. Education Training Programs5
The ACGME accredits:
A. Continuing Medical
Education Programs
B. Post-Medical
Education Training Programs
C. Federal Prisons
D. State Medical Boards

73. B. Post-Medical Education Training Programs

74. B. Initial applications6
The URAC time limit covering attestation statements is 180 days and applies only to:
A. Drug testing
B. Initial applications
C. Reappointment
applications
D. Medical licensure
application

75. B. Initial applications

76. B. Abide to confidentiality7
According to NCQA, if the application’s final approval exceeds 365 (305 CVO) days from the date of the signature, the applicant must reattest to:
A. Identity
B. Abide to confidentiality
C. Information correct
and complete
D. Names of peer
references

77. C. Information correct and complete

78. B. Medical Staff approval D. Notification of change8
What is the final step in changing Medical Staff Bylaws?
A. MEC approval
B. Medical Staff approval
C. Governing body
approval
D. Notification of change
to Medical Staff

79. D. Notification of change to Medical Staff

80. 9
Which of the following is NOT a Joint Commission designated equivalent source?
A. AANC
B. FSMB
C. AAPA
D. ECFMG

81. A. AANC

82. 10
HFAC requires three medical staff committees, which are the MEC, Utilization of Osteopathic Methods & Concepts Committee, and the _______ Committee.
A. Credentials
B. Peer Review
C. Utilization Review
D. CME

83. C. Utilization Review

84. 1
In Roberts Rules of Order, ____________ involve substantive proposals for consideration and action.
A. main motions
B. abstentions
C. quorums
D. majority votes

85. A. main motions

86. 2
NCQA has a board certification verification time limit of _________ for CVO’s:
A. 120 days
B days
C days
D. 365 days

87. A. 120 days

88. 3
In NCQA, this process can be used when it is in the best interest of members to have the practitioner available before the initial credentialing process is complete.
A. Temporary credentials
B. Conditional credentials
C. Provisional credentials
D. Expedited credentials

89. C. Provisional credentials

90. 4
Which accreditor requires a mechanism to determine the applicant is the individual identified in the credentialing documents?
A. CMS
B. TJC
C. NCQA
D. AAAHC

91. B. TJC

92. Which accreditor requires an organization implement appropriate interventions by conducting site visits of offices about which it has received member complaints and those for which established thresholds are exceeded?
A. URAC
B. NCQA
C. AAAHC
D. CVO

93. B. NCQA

94. 6
Cordotomy, rhizotomy, and dorsal column stimulators are performed by a(n):
A. Allergy and
Immunologist
B. Dermatologist
C. Neurosurgeon
D. Thoracic Surgeon

95. C. Neurosurgeon

96. 7
Which of the following is NOT a required element of a research study informed consent?
A. Statement study
involves research
B. Explanation of
purpose of research
C. Expected duration
of participation
D. Name of FDA agent

97. D. Name of FDA agent

98. C. expiration of license8
According to TJC, query of the NPDB is required when clinical privileges are granted, renewed, and:
A. new privileges are
requested
B. retirement
C. expiration of license
D. whenever MSO
feels like it

99. A. new privileges are requested

100. An embolectomy is performed by a:9
An embolectomy is performed by a:
A. Neurologist
B. Orthopedist
C. Plastic Surgeon
D. Vascular Surgeon

101. D. Vascular Surgeon

102. 10
NCQA DOES NOT require the following information be listed on the organizations web-based physician directory:
A. gender
B. medical school
C. board certification
D. languages spoken

103. B. medical school

104. 1
According to TJC, which of the following is an appropriate source for peer recommendations?
A. NPDB
B. AMA
C. MEC
D. P&T Committee

105. C. MEC

106. 2
A formal process by which the organization gives another entity the authority to perform certain functions on its behalf
A. Delegation
B. Distribution
C. Expedition
D. Automation

107. A. Delegation

108. What is the number one reason for credentialing?3
What is the number one reason for credentialing?
A. Patient safety
B. Risk management
C. Meet accreditation
standards
D. To give MSPs a job

109. A. Patient safety

110. According to AAAHC, the governing body must meet at least ___________.4
According to AAAHC, the governing body must meet at least ___________.
A. monthly
B. quarterly
C. semi-annually
D. annually

111. D. annually

112. C. Chief Medical Officer5
NCQA standards allow the Credentialing Committee to give the ___________ , or approved qualified physician designee, authority to evaluate and approve applications.
A. Department Chair
B. Medical Director
C. Chief Medical Officer
D. Chairman of the Board

113. B. Medical Director

114. 6
According to CMS, this is one criteria required for the governing body to use in making selections to the medical staff:
A. technical expertise
B. treatment ability
C. character
D. experiments

115. C. character

116. 7
According to TJC, a practitioner’s quality of care is assessed during reappointment through analysis of:
A. length of stay
B. complex cases
C. aggregate data
D. patient complaints

117. C. aggregate data

118. A. Lack of present Illegal8
NCQA requires attestation of the following:
A. Lack of present Illegal
drug use
B. Lack of current
substance abuse
C. Lack of present
chemical dependency
D. Lack of partying

119. A. Lack of present illegal drug use

120. 9
Which of the following is NOT required for provisional credentialing of a provider?
A. PSV of DEA
B. PSV of license
C. NPDB
D. Current and
signed application

121. A. PSV of DEA

122. A. Respiratory Therapists D. Occupational Therapists10
According to CMS, the following non-physician practitioners may be eligible for medical staff privileges:
A. Respiratory Therapists
B. Massage Therapists
C. Medical Assistants
D. Occupational Therapists

123. D. Occupational Therapists

124. 1
According to CMS, _______ privileges should be reviewed and updated at least every two years.
A. Medical
B. Orthopedic
C. Surgical
D. Obstetrical

125. C. Surgical

126. 2
According to NCQA, signature stamps may not be used unless the practitioner is:
A. Physically impaired
B. Mentally impaired
C. Disruptive
D. Lazy

127. A. Physically impaired

128. 3
_________ requires the application / reapplication have a formal statement releasing the organization from any liability in connection with credentialing decisions.
A. URAC
B. CMS
C. DNV
D. AAAHC

129. D. AAAHC

130. A. AMA Physician Master File4
The following is an NCQA approved source for verification of board certification:
A. AMA Physician Master File
B. NPDB
C. HIPDB
D. Medical school

131. A. AMA Physician Master File

132. B. Physical accessibility5
According to NCQA, office site visits must be conducted for complaints that meet thresholds in this area:
A. Rudeness of staff
B. Physical accessibility
C. Cigarette butts in
parking area
D. Excessive noise

133. B. Physical accessibility

134. B. Rules and regulations6
According to URAC, parameters or triggers of potential quality of care issues that require further investigation must be included in ______.
A. Policy
B. Rules and regulations
C. Bylaws
D. Delegation
agreements

135. A. Policy

136. 7
________ requires hospitals to inform each patient whom to contact to file a grievance.
A. TJC
B. DNV
C. CMS
D HFAP

137. C. CMS

138. 8
For written verifications, NCQA uses what date to determine time limit compliance?
A. Date on letter
B. Date received
C. Postmark date
D. Date stamped

139. A. Date on letter

140. 9
“The _________ must assure that the medical staff has bylaws and that those bylaws comply with State and Federal law and the requirements of CoPs.”
A. Chief of Staff
B. MEC
C. Governing Body
D. CEO

141. C. Governing Body

142. 10
According to TJC, which of the following is NOT an acceptable method of documenting CME’s:
A. Certificates copies
B. Attestation statement
C. Information submitted
with licensure renewal
D. Android App

143. D. Android App

144. HFAP uses the acronym PCO instead of CVO. What does PCO stand for?1
HFAP uses the acronym PCO instead of CVO. What does PCO stand for?
A. Professional Credentialing
Organization
B. Profiles & Credentialing
Organization
C. Practitioner Credentialing
Organization
D. Practice Credentialing
Online

145. A. Professional Credentialing Organization

146. 2
HFAP requires that the medical staff application request information regarding any criminal history for what period of time?
A. 3-5 years
B. 5-8 years
C years
D years

147. C years

148. 3
CMS standards require the criteria for selection of medical staff are character, competence, training, judgment, and _____.
A. Education
B. Experience
C. Eligibility
D. Excellence

149. B. Experience

150. C. Hospital affiliations4
According to AAAHC, documentation of current competence is obtained from:
A. Peers
B. Case logs
C. Hospital affiliations
D. QAPI

151. A. Peers

152. 5
According to HFAP, the following designated source can be used for actions against a physician’s medical license:
A. NPDB
B. AOA / AMA Profile
C. ECFMG
D. FSMB

153. D. FSMB

154. FACIS is an acronym for:6
FACIS is an acronym for:
A. Federal Access Center
Informational Systems
B. Fraud & Abuse Control
Information Systems
C. Federal Abuse &
Corrections Information System
D. Fraud Alert & Correction
Information System

155. B. Fraud & Abuse Control
Information Systems

156. A designated source for AAAHC is known as a “__________.”7
A designated source for AAAHC is known as a “__________.”
A. primary source
B. equivalent source
C. third-party source
D. secondary source

157. D. Secondary source

158. 8
According to TJC, disaster privileges may be granted to volunteer LIPs once the ______ has been activated.
A. Emergency
Operations Plan
B. Emergency
Disaster Plan
C. Emergency
Management Plan
D. Emergency
Facilities Plan

159. A. Emergency Operations Plan

160. 9
HFAP allows for what type of privileges to be used in time of emergency and/or disaster?
A. Provisional
B. Urgent
C. Emergent
D. Temporary

161. D. Temporary

162. 10
According to URAC standards, verification of DEA can be accomplished through either a copy of the DEA certificate or copy of:
A. NTIS Report
B. AOA / AMA Profile
C. FDA website
D. certificate number

163. D. certificate number

164. 1
According to URAC, what is the verification time limit for board certification?
A. 4 months
B. 6 months
C. 30 days
D. 60 days

165. B. 6 months

166. 2
NCQA standards consider the highest level of a practitioner’s training to be:
A. fellowship
B. residency
C. medical school
D. faculty

167. B. residency

168. 3
NCQA will allow verification from this site for closed residency programs.
A. ECFMG
B. NPDB
C. HIPDB
D. FCVS

169. D. FCVS

170. A. Institutional Research B. Institutional Review4
IRB is an acronym for which hospital committee
A. Institutional Research
Board
B. Institutional Review
Board
C. Internal Review
Board
D. Internal Research
Board

171. B. Institutional Review Board

172. URAC requires credentialing applications to include what information?5
URAC requires credentialing applications to include what information?
A. Substance
abuse problems
B. Chemical
dependency problems
C. Lack of illegal drug
use
D. Need for aspirin

173. A. Substance abuse problems

174. D. medical staff offices6
According to NCQA, ________ are responsible for the ongoing monitoring of sanctions or limitations on licensure between recredentialing cycles.
A. governing boards
B. medical staffs
C. organizations
D. medical staff offices

175. C. organizations

176. 7
HFAP requires, at least, how many years of past history of professional liability actions resulting in final settlements or judgments be evaluated.
A. Three
B. Five
C. Seven
D. Ten

177. B. Five

178. 8
In what timeframe does NCQA standards require credentialing decisions for initial appointment be communicated to the provider?
A. 30 calendar days
B. 30 business days
C. 60 calendar days
D. 60 business days

179. C. 60 calendar days

180. 9
According to URAC, Medicare / Medicaid sanctions can be verified with the issuing organization or _________.
A. HEDIS
B. NPDB
C. ABMS
D. CAHPS

181. B. NPDB

182. additional privileges10
According to DNV, OIG Medicare / Medicaid Exclusions must be verified at initial appointment, reappointment, and at what other time?
A. Request for
additional privileges
B. Request for change
in staff status
C. Granting temporary
privileges
D. Request for change
in privileges

183. C. Granting temporary privileges

184. Which accrediting agency does not require query of the NPDB?1
Which accrediting agency does not require query of the NPDB?
A. DNV
B. AAAHC
C. TJC
D. URAC

185. D. URAC

186. 2
Which accrediting agency requires peer recommendations at initial and reappointment?
A. URAC
B. AAAHC
C. NCQA
D. CMS

187. B. AAAHC

188. 3
DNV standards required how many peer recommendations for initial appointment?
A. None
B. One
C. Two
D. Three

189. C. Two

190. 4
According to NCQA, practitioners within the scope of credentialing include individual / group practices, facilities, telemedicine, and :
A. PCOs
B. government agencies
C. locums agencies
D. rental networks

191. D. Rental networks

192. 5
At a minimum, AAAHC requires physicians and __________ be credentialed and privileged.
A. Chiropractors
B. Optometrists
C. Dentists
D. Behavioral Health
Providers

193. C. Dentists

194. 6
Which accrediting agency requires the granting of privileges for each specific device.
A. TJC
B. DNV
C. HFAP
D. AAAHC

195. D. AAAHC

196. 7
The Utilization of Osteopathic Methods and Concepts Committee (HFAP) is only required for hospitals with how many admitting DO’s.
A. 10 or more
B. 20 or more
C. 30 or more
D. 40 or more

197. A. 10 or more

198. 8
TJC allows expedited credentialing by a committee consisting of at least 2 voting members of the:
A. MEC
B. Administration
C. Governing Body
D. Credentials
Committee

199. C. Governing Body

200. 9
Which accrediting agency requires a credentialing policy and procedure for the prevention and monitoring of discriminatory practices?
A. AAAHC
B. DNV
C. NCQA
D. TJC

201. C. NCQA

202. 10
Which accrediting agency requires the Credentials Committee have at least one member who is a participating practitioner who has no other role in organizational management?
A. TJC
B. HFAP
C. AAAHC
D. URAC

203. D. URAC

204. Thanks for playing!