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. Malpractice - ✔✔️A️AAHC, TJC, Medicare: Not fully addressed but states if bylaws require verification or proof of coverage, documentation must be obtained. All other organizations require proof and verification. Malpractice History - ✔✔️N️CQA: Pulled and verified with in the correct time frames (180 days or 120 days if CVO) URAC: 6 month time frame All require at minimum to verify history for the last 5 years. Accountable Care Organization - ✔✔️P️t Centered and includes offices, hospitals, nursing homes. The healthcare organization is characterized by a payment and care delivery model that 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. PSV by Telephone conversation - ✔✔️W️hen documenting a telephone conversation regarding primary source verification the name of the person and organization contacted, date of call, what was discussed and who conducted the interview should be included. Red Flags - ✔✔️U️nexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of According to HFAP standards on Malpractice Coverage - ✔✔️W️hen confirming malpractice coverage the organization must have evidence of professional liability coverage, which includes a certificate showing amounts of coverage. The governing body is obligated to: - ✔✔️a️ssure to the community that only appropriately educated, trained, and currently competent practitioners are granted medical staff membership and clinical privileges. Follow a routine process - ✔✔️w️hen credentialing and privileging practitioners it is appropriate to follow a routine process for each applicant. Medical liability insurance coverage limits - ✔✔️C️overage amounts should be held at the amounts specified by the medical staff, bylaws, or board of directors. However the industry standard for coverage limits is 1 million per occurrence and 3 milling annual aggregate. An appropriate question that can be asked by the medical staff - ✔✔️D️o you have any medical conditions, treated or untreated, that would negatively affect your ability to provide the services or perform the privileges you are requesting. The Medical Staff - ✔✔️T️he governing board delegates the responsibility of credentialing, recredentialing, and privileging Access to staff meeting minutes - ✔✔️P️ersonnel as documented in a records access policy and procedure. Meeting Minutes should include - ✔✔️I️n addition to conclusions, recommendations, and actions taken, meeting minutes should include any required follow up to occur. Active Staff - ✔✔️P️hysicians, dentist, osteopaths, and podiatrists who regularly provide patient care. Active staff pay dues, participate in special organizational and administrative functions, attend meetings, and may vote, hold office, and serve on committee's. 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 5. Communication sill 6. Interpersonal skills Respondeat Superior - ✔✔️L️et the master speak/answer Quorum - ✔✔️M️inimum number of members who must be present in a meeting in order to be able to conduct business American College of Surgeons - ✔✔️W️ere the first group to conduct hospital surveys AMA - ✔✔️A️merican Medical Association: publishes JAMA which is the largest circulation of weekly medical journal. This association publishes a list of physician specialty codes which are the standard method in the US for identifying physician and practice specialties ABMS - ✔✔️A️merican Board of Medical Specialties: organization of approved medical boards which represent broad areas of specialty medicine. Considered PSV for Board Certificates. ACGME - ✔✔️A️ccreditation Council for Graduate Medical Education: body responsible for accrediting the majority of graduate medical training programs such as internships, residencies, and fellowships. Unified the accreditation system for all MD's and DO's FSMB - ✔✔️F️ederation of State Medical Boards: Organization that represents the 70 state medical and osteopathic board of the United States. Primarily the FSMB license physicians, investigates complaints, and disciplines those who violate the law, conduct physician evaluations and facilitate rehab of physicians where appropriate. HIPAA - ✔✔️H️ealth Insurance Portability and Accountability Act of 1996 CDSS - ✔✔️C️linical Decision support system is a health information technology system that is designed to provide physicians and other health professionals with clinical decision support, that is, assistance with clinical decision making tasks. Tort - ✔✔️a️ wrongful act or an infringement of a right leading to civil liability The only organization that's standards require verification of applicant Identity - ✔✔️T️he Joint Commission Primary Sources for Board Certificate Verification - ✔✔️T️JC: ABMS or certified display agents/AOA NCQA: Appropriate specialty board; licensing agent, if said agent psv's board cert. must also verify highest level of education. HFAP: Board cert not required URAC: board cert of highest level of education AAAHC: verify board cert upon application, at reappointment, and upon expiration of certificate. CMS: Does not require board certs and says that you can not deny Medical Staff privileges solely based on if provider is board certified or not. Criminal Background Check - ✔✔️O️nly required by TJC and HFAP. No others require. HFAP only requires one Peer recommendation - ✔✔️H️FAP Standard for Peer Review According to NCQA standards PSV for Education - ✔✔️V️erification from the AMA is Acceptable for education and training completed through the AMA's fifth pathway program. According to CMS guidelines a roster listing each practitioners specific surgical privileges should be available - ✔✔️i️n the surgical suite and wherever surgical procedures are scheduled. According to NCQA standards for Medicare and Medicaid Sanctions - ✔✔️F️SMB is an acceptable source for PSV of Medicare and Medicaid sanction activity against providers Substantive and procedural - ✔✔️a️re two distinct elements of due process If a provider is on a GSA or OIG Exclusion List - ✔✔️N️either the practitioner nor the facility providing services to the patient at practitioners request can bill federal healthcare programs for care rendered. FACIS - ✔✔️a️ database containing adverse actions against an individual and entities sanctioned in the healthcare field and includes disciplinary actions ranging from exclusions to letters of reprimand and probation