CPMSM Test Questions & Answers | 207 Questions with 100% Correct Answers | Verified 2023, Exams of Economics

Download CPMSM Test Questions & Answers | 207 Questions with 100% Correct Answers | Verified 2023 and more Exams Economics in PDF only on Docsity! CPMSM Test Questions & Answers | 207 Questions with 100% Correct Answers | Verified 2023 HFAP - ✔✔️R️efers to a CVO as a Professional Credentialing Organization (PCO) HFAP Appointment time frame - ✔✔️2️ years TJC Appointment time frame - ✔✔️N️o longer than every 2 years NCQA Appointment time frame - ✔✔️3️ years (to the month) URAC Appointment time frame - ✔✔️3️ years AAAHC Appointment time frame - ✔✔️3️ years Attestation Statement - ✔✔️T️JC and Medicare do not specifically address, URAC allows electronic signature, all others require. Board Certification Verification - ✔✔️N️ot specifically required (only highest level of education) has to be verified within 180 days per NCQA or 120 days if CVO is verifying. CME - ✔✔️H️FAP may request every 2 years. TJC requires documentation. No others require. TJC views of Competence - ✔✔️M️onitoring of provider competence must be ongoing. URAC and NCQA views of Competence - ✔✔️M️onitoring of provider competence must be ongoing and organization must have policies for monitoring in place. HFAP view of Competence - ✔✔️C️ompetence can be monitored by proof of procedures performed. This can be done by the provider providing their procedure logs. AAAHC view of Competence - ✔✔️C️ompetence can be monitored by provided documentation of competency. Medicare view of Competence - ✔✔️G️overning body must verify character, competence, judgement, education, and training. Felony Conviction - ✔✔️O️nly addressed by a question or statement of provider application by NCAQ, HFAP, and AAAHC NCQA and URAC on Education - ✔✔️O️nly highest level of education verified. TJC and Medicare - ✔✔️D️oes no address Medicare and Medicaid sanctions. NPDB - ✔✔️N️CQA and URAC do not require it but it is an acceptable verification of sanctions. All other organizations require. Site Visit - ✔✔️N️CQA is the only organization that requires a site visit under certain circumstances. Temporary Privileges - ✔✔️A️AAHC and Medicare do not specifically address. Temporary Privileges granting requirements - ✔✔️T️his type of privilege can be granted by the CEO upon recommendation from the Chief of Staff or authorized designee as long as license, malpractice coverage, and NPDB have been verified. NCQA specifically says Provisional (Temporary) Privileges - ✔✔️C️an be granted by Chief Medical Official as long as their is a policy in place, the application is clean, and the privileges can be granted for no more than 60 days. Work History - ✔✔️U️RAC and Medicare do not address, NCAQ: History must be verified and any gaps of 6 months or greater require explanation. TJC & HFAP Work History - ✔✔️r️equire the question to be asked: Has the provider ever been terminated or suspended and NPDB must be compared to answer of the above question. AAAHC Work History - ✔✔️A️ny interruptions in employment must be accounted for. Health Status Form - ✔✔️A️ll organizations require a current statement of ability to perform as a provider. HFAP requires it to be documented from references. Views on Allied Health Professionals - ✔✔️N️CQA: Credentials all providers the same URAC: Adds that they must be listed in directory TJC & AAAHC: Say that MCO must distinguish providers as those with and without the need for supervision Medicare: Can grant privileges with or without Medical Staff rights. Disaster Plan - ✔✔️T️JC, HFAP, AAAHC require groups/organizations to have the plan documented and in place. DEA Verification - ✔✔️C️opies can be accepted, ensure there are no challenges to the certificate. Licensure - ✔✔️M️edicare: does not specifically address sanctions URAC: states that it has to be verified in a 6 month time frame. NCQA: Verified within 180 days (or 120 for CVO) All organizations require that the monitoring of licensure be ongoing. appointment, reappointment, and modifications of clinical privileges and makes recommendations to the Medical Executive Committee. This committee provides oversight for FPPE and OPPE. Should meet regularly. Utilization Management or Utilization Review Committee - ✔✔️E️nsures that all of the patient care given by the facility/providers is appropriate and provided effectively. Normally monitors topics such as: appropriateness of admission to the Hospital, delays in use of, or over use of ancillary services, delays in consultations and referrals, lengths of stay, and discharge planning. It is important to check that the practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal healthcare programs - ✔✔️b️ecause the facility will not get paid for treating patients unless service is provided by an authorized provider. According to NCQA standards, an organization that discovers sanction information, complaints, or adverse events regarding a practitioner must - ✔✔️f️irst determine if there is evidence of poor quality that could affect the health and safety of its members. Health Care Quality Improvement Act of 1986 - ✔✔️C️reated the National Provider Data Bank to restrict the ability of incompetent providers to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. When Developing clinical privileging criteria - ✔✔️i️t is important to evaluate the established standards or practice such as, specialty board recommendations Periodically assessing appropriateness of clinical privileges for each specialty - ✔✔️i️s important to protect patient safety by ensuring current competency, relevance to the facility, and accepted standards of care. TJC hospital standards require - ✔✔️c️linical privileges to be based on the individual's demonstrated current competence and the procedures the hospital can support. The only NCQA required committee - ✔✔️C️redentials Committee The 3 committees required by HFAP Standards - ✔✔️1️. Medical Executive Committee 2. Utilization of Osteopathic Methods and Concepts Committee (if there are 10 or more DO's on the Medical Staff. 3. Utilization Review Committee Peer References - ✔✔️S️hould be obtained from practitioners in the same professional discipline as the applicant. Patrick V. Burgett - ✔✔️I️llustrates the potential for antitrust liability arising our of peer review activities not performed in good faith. Due Process - ✔✔️I️f a medical staff member has privileges and / or medical staff appointment revoked he/she must be provided: Access Policy - ✔✔️A️ccess to Credentials files should be fully described in an access policy. Governing Body or Board - ✔✔️I️s the final approval of clinical privileges. Credentials Committee > Med Exec Med Exec > Board/Governing Body According to TJC Standards - ✔✔️I️nitial appointments to the medical staff are made for a period of time not to exceed two years. TJC requires the following items to be PSV - ✔✔️L️icensure, Training, experience, and competence Federation of State Medical Boards - ✔✔️A️ccording to NCQA standards, is an acceptable source for primary source verification of Medicare and Medicaid Sanction activity. The American Board of Medical Specialties - ✔✔️A️ccording to The Joint Commission standards, the ABMS is considered a designated equivalent source for verification of board certification. American Medical Association Mater File - ✔✔️I️s recognized by TJC and NCQA to provider primary source verification of medical school graduation and residency training for U.S. graduates. NCQA attestation statement must include - ✔✔️a️ffirmation that the application is correct and complete. According to TJC standards the Medical Staff Bylaws - ✔✔️S️hould define the structure of the Medical Staff According to TJC standards, professional criteria for granting of clinical privileges must include at least - ✔✔️R️elevant training or experience, ability to perform privileges requested, current licensure, and competence TJC Standards require the Medical Staff Bylaws to - ✔✔️i️nclude a mechanism for selection and removal of officers According to NCQA standards an appropriate verification source for verification of board certification - ✔✔️s️tate licensing agency, if state agency conducts primary verification of board status. TJC requires for Re-Appointment to the medical staff - ✔✔️P️rimary source verification of malpractice suits URAC's health network standards state - ✔✔️e️ach applicant within the scope of the credentialing program submits an application that includes at least -State licensure information, including current license(s) and history of licensure in all jurisdictions. According to AAAHC current Licensure - ✔✔️m️ust be monitored on an ongoing basis According to TJC a Nurse Practitioner - ✔✔️f️unctioning independently and providing a medical level of care must be granted delineated clinical privileges Education Commission of Foreign Medical Graduates - ✔✔️A️cceptable source for verification for medical education of an international graduate. NCQA requires board cert verification - ✔✔️I️n all cases (appointment and reappointment) AAAHC gives responsibility to: - ✔✔️t️he governing body for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management. Medicare Conditions of participation (MCoP) - ✔✔️I️n order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with: According to TJC's self governing medical staff standard - ✔✔️t️he medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges. A good rule of thumb for a Medical Staff application - ✔✔️i️s for the application to provide a chronological history of the applicant's education, training, and work history. Provider Panel - ✔✔️I️n order to participate in a managed care plan, a provider must be accepted to the plan's _________________. Current State Licensure - ✔✔️I️n order for any provider to practice medicine in any state he/she must first possess a Residency Training - ✔✔️I️s considered post-graduate education. Discrimination of any type - ✔✔️C️an not be used to evaluate credentials Release of Liability Statement - ✔✔️R️elease statement signed by the applicant for medical staff appointment should include a statement providing immunity to those who respond in good faith to request for information. level of care to hospitalized patients, diagnose and treat acute illnesses or perform various medical procedures while the patient is hospitalized. Hospitalists, however, confine their practice exclusively to the hospital and often have specialized training in nonmedical subjects related to that field. Internal Medicine - ✔✔️I️nternal medicine is a primary care field. Although some internists specialize in adolescent medicine, most internists care only for adult patients who have a variety of diseases, including chronic medical problems such as diabetes or acute problems such as pneumonia. Internal medicine has a number of subspecialties, such as infectious disease, rheumatology, gastroenterology and cardiovascular disease. Internists might see patients in the hospital or perform procedures there, but they spend most of their days in an office or clinic, where they see multiple patients, many of whom they care for over an extended period of months or years Hospitalist - ✔✔️H️ospital medicine developed in response to changes in reimbursement practices and demands on primary care physicians. Many physicians are unwilling to care for uninsured patients or take hospital calls, and teaching hospitals have restricted the hours that medical residents are allowed to work. The combination of these factors created a demand for physicians who could manage hospitalized patients and be available for emergencies. A hospitalist might see a patient only once in her lifetime and is more likely to be responsible for hospital-wide quality improvement efforts. William T. Ford, Ph.D., a hospitalist at Temple University Health System in Philadelphia, writes in the August 2009 issue of Today's Hospitalist that in many respects, the hospital itself is his "patient." Privileges - ✔✔️a️ term used to describe the access granted and basic framework for the rights or activities which are specifically provided to individuals by the Medical Staff of an organization, hospital, or facility. House Staff - ✔✔️a️ term used to describe interns and residents in medical education programs of teaching hospitals. Procedure rights of Fair Hearing - ✔✔️T️he mechanism by which an aggrieved practitioner, one who has been the recipient of disciplinary action, is entitled to he heard and to appeal an adverse decision Darling vs Charleston Memorial Community Hosptial - ✔✔️L️andmark case that set aside the Charitable Immunity Doctrine and established the Corporate Negligence doctrine, also known as negligent credentialing. "Anti-Dumping Law" - ✔✔️E️MTALA is the Federal law enacted to stop hospitals from transferring, discharging, or refusing to treat indigent patients coming to the emergency room/department because of cost factors. Informed Consent - ✔✔️E️thical issue practitioners face when explaining the risks and benefits of a particular course of treatment, allowing the patient to participate in decisions regarding treatment options, and confidentiality. Healthcare Quality Improvement Act (HCQIA) - ✔✔️d️efines the elements of due process that must be followed in order for an organization to have peer review protection. Centers for Medicare and Medicaid Services - ✔✔️T️he code of Ethics includes the language "shall share knowledge, foster educational opportunities, and encourage personal and professional growth through continued self-improvement and applications of current advancements in the profession"? Medical Staff President or Chief of Staff - ✔✔️I️s responsible for enforcing the medical staff bylaws, rules, and regulations, and procedural guidelines of the medical staff including imposing sanctions for non compliance. Department - ✔✔️T️erm that defines a functional unit of the hospital, so designated because of the clinical service it performs Department Chair - ✔✔️E️ach department of the Hospital, usually has its own department committee that consists of all of the practitioners that fall within that specialty. That department will elect a representative to be the spokesperson for that group of providers. That spokesperson will recommend criteria for clinical privileges of the department. The AMA's PRA Category 1 Credit System - ✔✔️T️he CME standard for licensing boards and specialty organizations nationwide and is recognized by the U.S. Jurisdictions State Operations Manual - Appendix A Survey Protocol, Regulations and Interpretive Guidelines for Hospitals - ✔✔️D️ocument that surveyors for the Centers of Medicare and Medicaid Services reference when surveying a hospital. Average Length of Stay (ALOS) - ✔✔️O️ne measure of hospital utilization review. Accreditation - ✔✔️R️ecognition that is granted to an institution (such as a health care provider or health plan) by a professional association or non-governmental agency demonstrating that the institution meets pre-established standards. Certification - ✔✔️R️ecognition that is granted to an individual health care worker by a professional association or nongovernmental agency demonstrating the individual's competency relative to a pre-determined set of criteria Clinical Practice Guideline - ✔✔️A️ standard of care based on current, high-quality evidence that outlines the recommended course of care, including relevant options and their outcomes, and that is designed to help providers make the best possible care decisions. Disparities in health care - ✔✔️V️ariations in access to care and in health outcomes due to factors such as race, ethnicity, gender, and socioeconomic status. Evidence-based care - ✔✔️H️ealth care that applies the best available research (evidence) when making decisions about a patient's care. Morbidity - ✔✔️T️he incidence of disease, or how frequently a condition or illness occurs in a given population Patient experience - ✔✔️T️he full range of patients' interactions with the health care system, from scheduling appointments to interactions with their providers to the course of treatment, including whether these interactions meet patient needs and health goals. Patient-centered care - ✔✔️H️ealth care that recognizes and incorporates the distinct wishes and needs of individual patients, with an emphasis on patient values and preferences. Quality measure - ✔✔️A️ tool that is used to measure performance against a recognized standard of care Standard of Care - ✔✔️C️are that is delivered in accordance with clinical practice guidelines or other evidence-based care protocols. HCAHPS - ✔✔️T️he Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) is a formal public reporting initiative that measures patients' perspectives on hospital care Complaints - ✔✔️A️ll organizations (TJC, NCQA, HFAP, URAC, AAAHC, and Medicare) must establish a process for addressing and handling complaints. Most agree that complaints should be continually monitored for all sites and providers. A mechanism for investigating the credibility of the complaint, implementing appropriate actions and continually monitoring those actions until the deficiency is resolved should in in place and formally published in a guideline that can be reviewed by others. Patients should easily be able to retrieve information on how and with who they can file a complaint. According to TJC peer reference should include 6 items - ✔✔️1️. Medical knowledge 2. Technical skill 3. Clinical judgement 4. Professionalism Release of Negative information - ✔✔️A️ special release developed my the Med Exec Committee should be obtained for the release of negative information to another facility USMLE - ✔✔️U️nited States Medical Licensing Exam OIG - ✔✔️O️ffice of Inspector General Reasons for Audits - ✔✔️C️omply with requirements Negligent Credentialing Issues Tool for Performance Evaluation Everyone Makes Mistakes Audits are performed by - ✔✔️D️etermine process to be audited Select Files Review files and log results Compile a master report of findings Share results DX - ✔✔️D️iagnosis Tx - ✔✔️T️reatment Sx - ✔✔️S️ymptoms C & X - ✔✔️w️ith, without SOB - ✔✔️S️hortness of Breath CFR / eCFR - ✔✔️C️ode of Federal Regulations / electronic Code of Federal Regulations When verifying licensure sanctions for physicians NCQA allows verification to be done with - ✔✔️N️PDB, HIPDB, the appropriate state agency and FSMB HIPAA Stands for - ✔✔️H️ealth Insurance portability and accountability act. Internal Criteria - ✔✔️C️riteria that a specific Medical Staff requires. example: Malpractice coverage limits Practitioner that has clinical privileges without Medical staff membership - ✔✔️o️ne granted temporary privileges. (The access to take care of patients in the facility but not admission into the medical staff until fully approved through committee) Itis - ✔✔️I️nflammation of osis - ✔✔️a️bnormal condition of gastro - ✔✔️s️tomach hepato - ✔✔️l️iver nephro/rene - ✔✔️K️idney derm - ✔✔️S️kin hemo/emia - ✔✔️b️lood Deposition - ✔✔️t️he sworn statement made by a witness that can be used as evidence in a court of law Delineation of Clinical Privileges - ✔✔️R️equire a listing of each and every individual procedure the applicant is approved to perform In order for a hospital to participate in the Medicare program - ✔✔️I️t must have an effective, Hospital wide quality improvement program Types of Reports submitted to NPDB - ✔✔️1️. Initial Report: first report notifying NPDB of subject 2. Correction Report: Edits the initial report. 3. Void Report: Cancels or revokes the initial report and removes it from the system. 4. Revision-to-Action Report: is used to notify the NPDB that additional actions have been taken in addition to the initial report. Entities who can report to the NPDB - ✔✔️A️ny entity that provides health care and is registered to query can also submit to the NPDB. Also any Federal or state organization, peer review association, med society, or any group in that capacity can report information to the NPDB. If you submit a Report to the NPDB you must - ✔✔️A️lso submit a copy of the report to the appropriate state licensing board. AMA PRA Category 2 Credit - ✔✔️i️s defined as educational activities not designated for AMA PRA Category 1 Credit™ that: (1) comply with the AMA definition of CME; (2) comply with the AMA ethical opinions on Gifts to Physicians from Industry and on Ethical Issues in CME (i.e., are not promotional); (3) and a physician finds to be a worthwhile learning experience related to his/her practice. AMA PRA Category 1 Credit - ✔✔️A️MA PRA Category 1 Credit™ represents that the physician has participated in an educational activity, and completed all requirements for such an activity, that is expected to "serve to maintain, develop, or increase the knowledge, skills, and professional performance and relationships that a physician uses to provide services for patients, the public or the profession" as stated in the AMA's definition of CME. Examples of Category 1 CME - ✔✔️L️ive Activities Enduring Materials Journal Based CME Test item writing Manuscript review Performance Improvement Internet Point of Care Learning Examples of Category 2 CME - ✔✔️T️eaching residents, med students, other health care professional Unstructured online searching and learning Reading authoritative Med literature Consultation with peers and medical experts Small group discussions Self assessment activities Medical Writing Preceptorship Participation Research Peer review and quality assurance participation