2025 Practice Test Flashcards
(154 cards)
1
Q
Why is it important to check that a practitioner is not currently excluded, suspended, debarred, or ineligible to participate in Federal health care programs?
A. A facility could lose its accreditation if it does not do so.
B. It is required by Medical Conditions of Participation
C. The facility won’t get paid for treating patients unless service is provided by an authorized provider
A
C. The facility won’t get paid for treating patients unless service is provided by an authorized provider
2
Q
Which of the following credentials must be tracked on an ongoing basis?
A. Medical school completion
B. Closed medical malpractice claims
C. Licensure
A
C. Licensure
3
Q
According to NCQA standards, an organization that discovers sanction information, complaints, or adverse events regarding a practitioner must take what action?
A. Determine if there is evidence of poor quality that could affect the health and safety of its members
B. Immediately take action to remove the provider from its panel
C. Initiate Ongoing Professional Practice Evaluation
A
A. Determine if there is evidence of poor quality that could affect the health and safety of its members
4
Q
What is the name of the entity that was established through the Health Care Quality Improvement Act of 1986 to restrict the ability of incompetent physicians, dentists, and other health care practitioners to move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action
A. Emergency Medical Treatment and Active Labor Act
B. The National Practitioner Data Bank
C. The Patient Safety and Quality Improvement Act
A
B. The National Practitioner Data Bank
5
Q
When developing clinical privilege criteria, which of the following is important to evaluate?
A. How many providers are in that specialty
B. Established standards of practice such as specialty board recommendations
C. Whether or not the quality department can support the FPPE process
A
B. Established standards of practice such as specialty board recommendations
6
Q
What is the main reason for periodically assessing appropriateness of clinical privileges for each specialty?
A. It’s required by accreditation standards
B. It’s required by Medicare Conditions of Participation
C. To protect patient safety by ensuring current competency, relevance to the facility, and accepted standards of care.
A
C. To protect patient safety by ensuring current competency, relevance to the facility, and accepted standards of care
7
Q
Which of the following specialists is most likely to perform a PTCA?
A. General surgeon
B. OBGYN
C. Interventional Cardiologist
A
C. Interventional Cardiologist
8
Q
The Joint Commission hospital standards require that clinical privileges are hospital specific and
A. Based on the individual’s demonstrated current competence and the procedures the hospital can support
B. Based on board certification
C. Based on the privileges the individual is currently approved to perform at other hospitals
A
A. Based on the individual’s demonstrated current competence and the procedures the hospital can support
9
Q
Which of the following would be routinely performed by a cardiologist?
A. Hysterectomy
B. Transesophageal Echocardiography
C. Urethral dilation
A
B. Transesophageal Echocardiography
10
Q
Which NCQA required committee makes recommendations regarding credentialing decisions?
A. Medical Executive Committee
B. Quality Care Committee
C. Credentialing Committee
A
C. Credentialing Committee
11
Q
ACHC standards require two medical staff committees to be delineated in the medical staff structure. One of them is the Medical Executive Committee. What is the other required medical staff committee?
A. Credentials Committee
B. Investigative Review Board
C. Utilization Review Committee
A
C. Utilization Review Committee
12
Q
If you needed to find out about what the federal government requires in regards to anti-trust issues, what law would you consult?
A. Healthcare Quality Improvement Act
B. Patient Safety and Quality Improvement Act
C. Sherman Anti-trust Act
A
C. Sherman Anti-trust Act
13
Q
Peer references should be obtained from:
A. Practitioners who have referred patients to the provider
B. Family, friends, and neighbors
C. Practitioners in the same professional discipline as the applicant
A
C. Practitioners in the same professional discipline as the applicant
14
Q
Patrick v. Burnett is an important case because it:
A. Showed that a hospital can assert that peer review is performed at the state’s request
B. Illustrates that the governing body is the ultimate authority
C. Illustrates the potential for anti trust liability arising out of peer review activities
A
C. Illustrates the potential for anti trust liability arising out of peer review activities
15
Q
If a medical staff member has privileges and/or medical staff appointment revoked, he/she must be:
A. Granted temporary privileges
B. Provided due process
C. Reported immediately to the National Practitioner Databank
A
B. Provided due process
16
Q
Access to credentials files should be:
A. Available to all members of the organization’s staff
B. Described fully in an access policy
C. Available to the organization’s patients and potential patients
A
B. Described fully in an access policy
17
Q
Which of the following bodies approves clinical privileges?
A. Credentials Committee
B. Peer Review Committee
C. Governing Body or Board
A
C. Governing Body or Board
18
Q
What primary source verification is required by NCQA prior to provisional credentialing?
A. Current compliance
B. Licensure and 5 year malpractice history or NPDB
C. Education and Training
A
B. Licensure and 5 year malpractice history
19
Q
According to The Joint Commission standards, initial appointments to the medical staff are made for a period of:
A. Two years
B. Four years
C. Not to exceed three years
A
C. Not to exceed three years
20
Q
According to The Joint Commission standards, temporary privileges may be granted by:
A. The department chair
B. The CEO
C. The CEO on the recommendation of the medical staff president or authorized designee
A
C. The CEO on the recommendation of the medical staff president or authorized designee
21
Q
According to The Joint Commission standards, which of the following items must be verified with a primary source?
A. Medicare/Medicaid Sanctions
B. Proof of professional liability insurance
C. Licensure, training, experience, and competence
A
C. Licensure, training, experience, and competence
22
Q
According to NCQA standards, a copy of which of the following is acceptable verification of the document?
A. DEA certificate
B. Licensure
C. Board certification
A
A. DEA certificate
23
Q
According to NCQA standards, which is an acceptable source for primary source verification of Medicare and Medicaid sanction activity against a physician?
A. Federation of State Medical Boards
B. American Board of Medical Specialities
C. Education Commission on Foreign Medical Graduates Profile
A
A. Federation of State Medical Boards
24
Q
According to The Joint Commission standards, which of the following is considered a designated equivalent source for verification of board certification?
A. The American Board of Medical Specialities
B. Education Commission on Foreign Medical Graduates Profile
C. Federation of State Medical Boards
A
A. The American Board of Medical Specialities
25
Which of the following organizations have been recognized by The Joint Commission and NCQA to provide primary source verification of medical school graduation and residency training for U.S. graduates?
A. American Medical Association Physician Masterfile
B. National Practitioner Data Bank
C. Federation of State Medical Boards
A. American Medical Association Physician Masterfile
26
According to NCQA standards, the application attestation statement must affirm that the application:
A. Is correct and complete
B. Was actually completed by the provider
C. Was signed in the presence of a notary public
A. Is correct and complete
27
According to The Joint Commission standards, medical staff bylaws should define:
A. The structure of the medical staff
B. Mechanism for appointment/reappointment of physician employed non-independent practitioners
C. A requirement that departments meet on at least a quarterly basis
A. The structure of the medical staff
28
According to The Joint Commission standards, professional criteria for the granting of clinical privileges must include at least:
A. Relevant training or experience, ability to perform privileges requested, current licensure, and competence
B. Verification of all current and prior malpractice suits filed and settlements made
C. Letters of reference from the Chief Executive Officer of all current and prior hospital affiliations
A. Relevant training or experience, ability to perform privileges requested, current licensure, and competence
29
The Joint Commission standards require medical staff bylaws to include:
A. A mechanism for selection and removal of officers
B. A requirement that all quality of care information be reviewed by the medical staff president
C. A mechanism for removal of the hospital’s chief executive officer
A. A mechanism for selection and removal of officers
30
According to NCQA standards, which of the following is an approved source for verification of board certification?
A. National Practitioner Data Bank
B. State licensing agency if state agency conducts primary verification of board status
C. Viewing of the original board certificate
B. State licensing agency if state agency conducts primary verification of board status
31
According to The Joint Commission standards, which of the following is a required component of the reappointment process?
A. Documentation of the applicant’s health status
B. Verification of residency training
C. Medicare/Medicaid sanctions query
A. Documentation of the applicant’s health status
32
According to URAC’s health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following?
A. State licensure information, including current license(s) and history of licensure information in all jurisdictions
B. A listing of all current and past hospital affiliations
C. A NPDB self-query
A. State licensure information, including current license(s) and history of licensure information in all jurisdictions
33
According to AAAHC, which must be monitored on an ongoing basis?
A. Current licensure
B. Medical malpractice liability coverage
C. Health status
A. Current licensure
34
According to The Joint Commission, a nurse practitioner functioning independently and providing a medical level of care must:
A. Have a job description
B. Be granted delineated clinical privileges
C. Be directly supervised by an active physician staff member
B. Be granted delineated clinical privileges
35
According to The Joint Commission, which of the following is an acceptable source for verification for medical education of an international graduate?
A. Board certification
B. Federation of State Medical Boards
C. Education Commission for Foreign Medical Graduates
C. Education Commission for Foreign Medical Graduates
36
When evaluating compliance with the required timeframe for recredentialing, NCQA counts the recredentialing period to the:
A. Day
B. Week
C. Month
C. Month
37
NCQA standards require the organization to verify board certification at recredentialing:
A. If a practitioner has received Medicare/Medicaid status
B. If a practitioner is requesting a change in status
C. In all cases
C. In all cases
38
To whom does the AAHC give the responsibility for approving and ensuring compliance with policies and procedures related to credentialing, quality improvement, and risk management?
A. Medical staff
B. Credentials committee
C. Governing body
C. Governing body
39
In order for a healthcare facility to participate in the Medicare and Medicaid programs it must comply with:
A. Medicare Conditions of Participation
B. The Joint Commission of Accreditation of Healthcare Organizations standards
C. National Committee for Quality Assurance (NCQA) standards
A. Medicare Conditions of Participation
40
According to The Joint Commission standards, which of the following is an element of a self governing medical staff?
A. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges
B. There can be any number of organized medical staffs as long as they are approved by the governing body
C. The hospital’s board of directors determines the criteria for granting medical staff privileges
A. The medical staff determines the mechanism for establishing and enforcing criteria for assigning oversight responsibilities to practitioners with independent privileges
41
Robert’s Rules of Order is an example of:
A. Executive privilege
B. Parliamentary procedure
C. A code of conduct
B. Parliamentary procedure
42
The medical staff application should provide a chronological history of:
A. The applicant’s education, training, and work history
B. CME activities and completion of residency
C. Marriages since medical school
A. The applicant’s education, training, and work history
43
In order to participate in a managed care plan, a provider must be accepted to the plan’s:
A. Provider panel
B. Medical staff
C. Medical team
A. Provider panel
44
In order for a physician to practice medicine in any state in the United States, he/she must possess:
A. Malpractice insurance with limits of at least $1 million per occurrence and $3 million annual aggregate
B. Membership on the provider panel of the majority of the state’s major managed care plans
C. Current state licensure
C. Current state licensure
45
A primary enrollment responsibility is:
A. Negotiate fee schedules with payers
B. Perform primary source verifications
C. Submit required documents and forms
C. Submit required documents and forms
46
Which of the following elements may not be used to evaluate credentials of applicants?
A. Gender
B. Licensure
C. Post graduate training
A. Gender
47
The release of liability statement signed by the applicant for medical staff appointment should include:
A. The name of the department chairman for all past hospital appointments
B. A statement providing immunity to those who respond in good faith to requests for information
C. A statement of the correctness of the information provided
B. A statement providing immunity to those who respond in. Good faith to requests for information
48
Primary source verification is:
A. Receiving information directly from the issuing source
B. Required by the healthcare quality improvement act
C. Considered economic credentialing
A. Receiving information directly from the issuing source
49
Unexplained delays between graduation and medical school, incomplete training, and unexplained lapses in professional practice are examples of:
A. Red flags
B. Medicare sanctions
C. Events reportable to the National Practitioner Data Bank
A. Red flags
50
When documenting a telephone conversation regarding primary source verification, what should be documented?
A. The date and time of the call only
B. Who answered the call
C. Name of person and organization contacted, date of call, what was discussed, and who conducted the interview
C. Name of person and organization contacted, date of call, what was discussed, and who conducted the interview
51
According to ACHC standards, when confirming malpractice coverage, the organization must:
A. Query the NPDB
B. Obtain the claim history with each carrier over the last five years
C. Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
C. Have evidence of professional liability insurance, which includes certificate showing amounts of coverage
52
Which of the following providers is considered a primary care physician (PCP)?
A. General surgeon
B. Gastroenterologist
C. Family medicine practitioner
C. Family medicine practitioner
53
Which body has the obligation to the community to assure that only appropriately educated, trained and currently competent practitioners are granted medical staff membership and clinical privileges?
A. Medical Staff
B. Governing Body
C. The Joint Commission
B. Governing Body
54
When credentialing and privileging practitioners it is appropriate to:
A. Handle each applicant on a case-by-case basis
B. Follow a routine process for each applicant
C. Give preferential treatment to those providers whose specialty is primary care
B. Follow a routine process for each applicant
55
Medical liability insurance should be held in what limits?
A. $500,000 per occurrence and $1,000,000 annual aggregate
B. $1,000,000 per occurrence and $3,000,000 annual aggregate
C. As specified by the medical staff and board of directors
C. As specified by the medical staff and board of directors
56
Which of the following would be an appropriate question to ask an applicant for medical staff?
A. How many children do you have?
B. Are you married?
C. Do 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?
C. Do 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?
57
The governing body delegates the task of credentialing, recredentialing, and privileging to:
A. The hospital administrator
B. The medical staff office
C. The medical staff
C. The medical staff
58
Who should have access to medical staff meeting minutes?
A. Medical staff president
B. Governing body members
C. Personnel as documented in a records access policy and procedure
C. Personnel as documented in a records access policy and procedure
59
In addition to conclusions, recommendations made, and actions taken, which of the following should always be documented in meeting minutes:
A. Exact details of conversations held
B. Date and location of next scheduled meeting
C. Any required follow-up to occur
C. Any required follow-up to occur
60
Active, Associate, Courtesy, Honorary, Consulting are all examples of:
A. Committees
B. Medical staff officers
C. Membership categories
C. Membership categories
61
Changes in medical staff bylaws are not final until formally approved by the:
A. Medical staff
B. Medical staff president
C. Governing body
C. Governing body
62
What is the only hospital medical staff committee required by The Joint Commission?
A. Credentials committee
B. Medical executive committee
C. Pharmacy and therapeutics committee
B. Medical executive committee
63
The Healthcare Quality Improvement Act:
A. Provides immunity for health care entities that do not report information to the National Practitioner Data Bank
B. Keeps hospitals and physicians who perform peer review from being sued
C. Provides qualified immunity from antitrust liability arising out of peer review activities that are conducted in good faith
C. Provides qualified immunity from antitrust liability arising out of peer review activities that are conducted in good faith
64
If you have a question regarding whether or not information regarding a practitioner should be released to a third party, which of the following would be the best person to ask?
A. Director of Medical Records
B. Chief of Staff
C. Organization’s attorney
C. Organization’s attorney
65
Prior to releasing information to a third party regarding a practitioner, the organization should acquire:
A. A picture ID of the provider
B. A signed consent and release form
C. Approval from the organization’s attorney
B. A signed consent and release form
66
You are working at an AAAHC accredited facility and you want to introduce the concept of utilizing a credentials verification organization. If the CVO is not accredited by a nationally recognized organization, you must:
A. Perform an initial on-site visit of the CVO to assess their capabilities and quality of work
B. Perform an assessment of the capability and quality of the CVO’s work
C. Perform an assessment of their turnaround times
B . Perform an assessment of the capability and quality of the CVO’s work
67
What are the three major sources of authority in the traditional structure of the hospital organization?
A. Chief executive officer, governing body, and medical staff
B. Chief executive officer, hospital vice president, medical director
C. Medical staff president, vice president, and secretary-treasurer
A. Chief executive officer, governing body, and medical staff
68
How does the governing body of a hospital set the organization policy that supports quality patient care?
A. By assigning these responsibilities to the chief executive officer
B. By seeking medical staff input in the hiring of key personnel
C. By developing the mission, vision, policies, and bylaws that govern the hospital’s operations
C. By developing the mission, vision, policies, and bylaws that govern the hospital’s operations
69
Governing boards may be generally classed into which two types?
A. For profit or not for profit
B. Philanthropic or corporate
C. General or specialty
B. Philanthropic or corporate
70
Which of the following is a major responsibility of the CEO?
A. Directly observing nursing care to assure that patients receive proper care and treatment
B. Keeping the medical staff informed about the hospital’s plans, organizational changes, board policies, and decisions affecting providers and their patients
C. Overseeing the patient accounts department to assure accurate billing practices
B. Keeping the medical staff informed about the hospital’s plans, organizational changes, board policies, and decisions affecting providers and their patients
71
To whom is the medical staff organization accountable for the quality of the professional services provided by individuals with clinical privileges?
A. The Joint Commission
B. Hospital CEO
C. Governing body
C. Governing body
72
Which term describes a physician employed or contracted by the hospital as a top level management employee to act as liaison between the medical staff and hospital administration?
A. Medical director
B. Chief financial officer
C. Medical staff president
A. Medical director
73
Which of the following are included in the functions of the medical staff?
A. Contracting for Medicare assignment
B. Training nursing staff
C. Providing and evaluating patient care
C. Providing and evaluating patient care
74
Which of the following describes a committee that is assembled or appointment to perform a specific task or duty, works independently and reports back to larger committee and typically disbands after the assigned task or duty is performed or completed?
A. Standing committee
B. Ad hoc committee
C. Task force
B. Ad hoc committee
75
When developing bylaws language for a committee, consideration should be given to which of the following?
A. The mission statement of the hospital
B. Medical staff restructuring
C. Composition, duties, and frequency of meetings
C. Composition, duties, and frequency of meetings
76
The credentials committee needs guidance regarding which physicians will be allowed to perform a new procedure in the hospital. It has recommended that a committee be appointed to evaluate this issue and report back to the credentials committee. What kind of committee would be appointed?
A. Standing committee
B. Ad hoc committee
C. Utilization review committee
B. Ad hoc committee
77
Which term describes a physician who provides the general medical care of hospitalized patients only and turns over the care of the patient to the primary care physician after discharge?
A. Internist
B. Hospitalist
C. Primary care provider
B. Hospitalist
78
Which term describes a category of medical staff appointment that provides a basic framework within which physicians and other health care providers carry out their duties and responsibilities?
A. Staff status
B. Privileges
C. Committee appointment
A. Staff status
79
Which term describes interns and residents in medical education programs of a teaching hospital?
A. Affiliate staff
B. Allied health professionals
C. House staff
C. House staff
80
Which term describes a special classification use to reflect honor and respect for selected distinguished members of the medical community?
A. Consulting staff
B. Active staff
C. Honorary or emeritus staff
C. Honorary or emeritus staff
81
Which term describes privileges granted for a specific period of time to a practitioner while hospital board approval is pending?
A. Temporary privileges
B. Provisional staff
C. Interim appointment
A. Temporary privileges
82
Which document describes the organizational structure of the medical staff and defines the framework within which medical staff appointees act and interact in hospital-related activities?
A. Fair hearing plan
B. Joint Commission Comprehensive Accreditation Manual
C. Medical staff bylaws
C. Medical staff bylaws
83
Which of the following is a required activity for Medicare and Medicaid enrollment?
A. Revalidation
B. Recredentialing
C. Rosters
A. Revalidation (not sure of this answer due to two answers on key)
84
Which term describes the mechanism by which an aggrieved practitioner, one who has been the recipient of disciplinary action, is entitled to be heard and to appeal an adverse action?
A. Medical staff executive committee
B. Procedural rights or fair hearing
C. Corrective action
B. Procedural rights or fair hearing
85
What landmark case set aside the Charitable Immunity Doctrine and established the corporate negligence doctrine, also known as negligent credentialing?
A. Patrick v Burnett
B. Miller v Eisenhower General Hospital
C. Darling v Charleston Memorial Community Hospital
C. Darling v Charleston Memorial Community Hospital
86
What is the name of the act, know as the Federal “anti dumping” law, which was enacted to stop hospitals transferring, discharging, or refusing to treat indigent patients coming to the emergency department because of cost factors?
A. Emergency Medical Treatment and Active Labor Act (EMTALA)
B. Transfer of Indigent Patients Act
C. Sherman Act
A. Emergency Medical Treatment and Active Labor Act (EMTALA)
87
In a hospital setting, the need for informed consent, explaining the risks and benefits of a particular course of treatment, allowing the patient to participate in decisions regarding treatment options, and confidentiality are all examples of what?
A. Peer review
B. Ethical issues
C. Credentialing
B. Ethical issues
88
Which act mandates regulations that prohibit disclosure of health information except as authorized by the patient or specifically permitted by the regulation?
A. Hospital Licensing Act (HLA)
B. Health Insurance Portability and Accountability Act (HIPAA)
C. Emergency Medical Treatment and Active Labor Act (EMTALA)
B. Health Insurance Portability and Accountability Act (HIPAA)
89
Which act defines the elements of due process that must be followed in order for an organization to have peer review protection?
A. Health Insurance Portability and Accountability Act of 1996 (HIPAA)
B. Emergency Medical Treatment and Active Labor Act (EMTALA)
C. Healthcare Quality Improvement Act (HCQIA)
C. Healthcare Quality Improvement Act (HCQIA)
90
The Code of Ethics for which organization 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”?
A. American Medical Association
B. American Hospital Association
C. NAMSS Certification Commission
C. NAMSS Certification Commission
91
What term is used to describe the evaluation or review of the performance of colleagues by professionals with similar types and degrees of clinical expertise?
A. Reappointment
B. Conditional period of appointment
C. Peer review
C. Peer review
92
Which medical staff officer is responsible for enforcing the medical staff bylaws, rules, and regulations, and procedural guidelines of the medical staff including imposing sanctions for noncompliance?
A. Credentials committee chairman
B. Medical staff president or chief of staff
C. Utilization Review Committee chairman
B. Medical staff president or chief of staff
93
Which term defines a functional unit of the hospital, so designated because of the clinical service it performs?
A. Department
B. Credentials committee
C. Peer review committee
A. Department
94
Which of the following is a responsibility of the department chairman?
A. Recommending criteria for clinical privileges in the department
B. Recommending amount of dues to be paid annually
C. Recommending to the medical executive committee the number of applicants to be allowed in the department
A. Recommending criteria for clinical privileges in the department
95
Which of the following is a Joint Commission requirement element for the process for managing LP health?
A. Participation in AAA meetings
B. Notification of patients regarding practitioner's participation in program
C. Education of LP and organization staff regarding recognizing illness and impairment issues specific to LPs
C. Education of LP and organization staff regarding recognizing illness and impairment issues specific to LPs
96
In the case of Frigo v Silver Cross Hospital, the podiatrist who performed surgery on Ms. Frigo did not meet initial criteria or revised criteria for Level II surgical privileges, but was granted privileges regardless. What was the legal concept under which the jury found Silver Cross Hospital to be negligent?
A. Breach of duty/corporate negligence
B. Respondeat superior
C. Antitrust
A. Breach of duty/corporate negligence
97
Which term below describes the achievement of the organization's objectives through and with people and other resources?
A. Planning
B. Staffing
C. Management
C. Management
98
Which continuing medical education system as become the CME standard for licensing boards and specialty organizations nationwide and is recognized by US jurisdictions?
A. The AMA's PRA Category 1 Credit system
B. The ACGME's CME program
C. FSMB's Profile Report
A. The AMA's PRA Category 1 Credit System
99
PECOS, the online enrollment system used by Medicare, stands for:
A. Provider Enrollment and Change Online System
B. Provider Enrollment Chain and Ownership System
C. Provider Enrollment, Claims, and Ownership System
B. Provider Enrollment Chain and Ownership System
100
Average Length of Stay (LOS) figures are used for which of the following purposes?
A. One measure of hospital utilization review
B. To calculate drug doses
C. Part of the calculation to determine reimbursement
A. One measure of hospital utilization review
101
Expenses that may vary directly with the quantity of work being performed are __________ costs.
A. Fixed
B. Semi variable
C. Variable
C. Variable
102
In a Joint Commission accredited hospital, applications for initial appointment to the medical staff must be acted on:
A. Within 90 days after the medical staff office receives the application
B. As specified in the medical staff bylaws
C. Within 30 days of receipt of completed application
B. As specified in the medical staff bylaws
103
Joint Commission standards require hospital-sponsored education activities to be prioritized and that, when developing these programs, they relate to:
A. The structure of the medical staff
B. The mission statement of the hospital
C. The type and nature of care, treatment, and services offered by the hospital
C. The type and nature of care, treatment, and services offered by the hospital
104
According to CMS's CoPs for hospitals, when utilizing telemedicine, the hospital must have evidence of an internal review of the distant-site physician's or practitioner's performance of these privileges and must send the distant-site hospital such performance information for use in the periodic appraisal of the distant-site physician or practitioner. At a minimum, this information must include:
A. Results of all quality assessment activities conducted by the distant site that pertain to telemedicine services
B. The entire credentials file of the telemedicine provider
C. All adverse events that result from the telemedicine services provided by the distant site physician or practitioner to the hospital's patients and all complaints the hospital has received about the distant site physician or practitioner
C. All adverse events that result from the telemedicine services provided by the distant site physician or practitioner to the hospital's patients and all complaints the hospital has received about the distant site physician or practitioner
105
According to Joint Commission standards, who must inform the patient about unanticipated outcomes of care, treatment, and services related to sentinel events?
A. Medical staff executive committee
B. Risk Manager
C. Responsible licensed independent practitioner or his or her designee
C. Responsible licensed independent practitioner or his or her designee
106
Which document contains a listing of drugs and pharmaceuticals maintained for use in the hospital?
A. Pharmacy procedure manual
B. Formulary
C. Prescription index
B. Formulary
107
According to Joint Commission standards, the qualifications and competence of a non-employee individual, other than a PA or APRN, who is brought into the hospital by an LP to provide care, treatment, must be assessed by:
A. The hospital
B. The department chairperson
C. The medical staff executive committee
A. The hospital
108
According to NCQA, the health plan must notify an initial applicant of the Credentialing Committee's decision within:
A. 30 days
B. 60 days
C. 180 days
B. 60 days
109
NCQA requires that an organization's policies and procedures describe specific credentialing system controls, including which of the following?
A. Confidentiality agreements signed by credentialing staff
B. Electronic signature for Medical Director review and approval of clean files
C. Unique user IDs and passwords
C. Unique user IDs and passwords
110
NCQA requires that recredentialing of practitioners and providers occur:
A. Every two years
B. Annually
C. At least every three years
C. At least every three years
111
Under NCQA standards, when credentialing activities are delegated by a health plan, the right to approve, terminate, or suspend individual practitioners or providers is retained by:
A. NCQA
B. The delegate
C. The health plan
C. The health plan
112
You are working at a AAAHC accredited facility. You are credentialing a new applicant, but the fellowship program has closed and you cannot find an organization that has the records. Which of the following is the best way to handle this situation?
A. Document in the credentials file that you couldn't verify
B. Attempt to get the information from another health care organization, such as a hospital or group practice that has carried out primary source or acceptable secondary source verification of the fellowship
C. Contact the applicant and tell him/her that he/she does not qualify for medical staff appointment since you cannot verify fellowship
B. Attempt to get the information from another health care organization, such as a hospital or group practice that has carried out primary source or acceptable secondary source verification of the fellowship
113
According to URAC's health network standards, each applicant within the scope of the credentialing program submits an application that includes at least which of the following:
A. State licensure information, including current license(s) and history of licensure in all jurisdictions
B. A listing of all current and past hospital affiliations
C. A NPDB self query
A. State licensure information, including current license(s) and history of licensure in all jurisdictions
114
Before granting of initial privileges, Joint Commission standards require the organization to verify current licensure, certification, or registration and training with the primary source. Which of the following is an additional Joint Commission requirement for new applicants?
A. Verifying that the applicant has not been excluded from Medicare, Medicaid, or other federal programs
B. Verification of professional liability (medical malpractice) insurance coverage
C. The applicant must attest that he or she has no health problems that could affect his or her ability to perform the requested privileges.
C. The applicant must attest that he or she has no health problems that could affect his or her ability to perform the requested privileges.
115
You are working at a Joint Commission accredited hospital. You are processing a reappointment for medical staff membership and clinical privileges, and you find that the practitioner has not performed any procedures at your facility since her last reappointment. The appointment is due to expire in one month. What should you do?
A. As long as there is no negative information received, process the application according to the approved process
B. Inform the applicant that she is not eligible for appointment due to not having provided services at your facility
C. Ask the applicant to provide names of other facilities where she is practicing, then write to those facilities to obtain documentation of procedures performed and outcome data, if available
C. Ask the applicant to provide names of other facilities where she is practicing, then write to those facilities to obtain documentation of procedures performed and outcome data, if available
116
According to ACHC standards, in addition to direct contact with the training program, which of the following is/are approved designated source(s) for verification of residency training?
A. AMA Physicians Profile for MDs and AOA Official Osteopathic Physician Profile for DOs
B. The state licensing boards if the organization confirms that the state board does verify residency
C. Confirmation from association of schools of health
A. AMA Physicians Profile for MDs and AOA Official Osteopathic Physician Profile for DOs
117
AAAHC standards require appointments to be for no longer than:
A. One year
B. Two years
C. Three years
C. Three years
118
Substantive and procedural are two distinct elements of:
A. Medical staff appointment
B. Due process
C. Privileging
B. Due process
119
Which of the following is a requirement of the Joint Commission for the medical staff?
A. Participation in the Maryland Quality Indicator Project
B. Reporting to the National Practitioner Data Bank and state licensing board those individuals who have had privileges suspended or revoked based on quality of care concerns
C. Define circumstances requiring focused review of a practitioner's performance
C. Define circumstances requiring focused review of a practitioner's performance
120
Which federal agency has been delegated the responsibility for conducting the Medicare program?
A. Centers for Medicare and Medicaid
B. Civilian Health and Medical Program
C. Federal Employee Health Benefits Program
A. Centers for Medicare and Medicaid
121
What term best describes the examination and evaluation of the appropriateness of use of an organization's resources to determine medical necessity and cost effectiveness of services provided?
A. Peer review
B. Resource based value system
C. Utilization review or utilization management
C. Utilization review or utilization management
122
Which is the term applied to initial appointment to the medical staff to permit observation for monitoring and evaluation of physician performance?
A. Temporary
B. Locum tenens
C. Provisional appointment
C. Provisional appointment
123
Which term applies to a practitioner filling in or working in place of another practitioner?
A. Temporary staff
B. Locum tenens
C. Provisiona member
B. Locum tenens
124
Which term is used to describe the use of criteria unrelated to quality of care or professional competency in determining an individual's qualifications for initial or continuing hospital medical staff appointment or privileges or continued participation in a provider panel of a managed care plan?
A. Credentialing criteria
B. Case management
C. Economic credentialing
C. Economic credentialing
125
New amendments to the Medicare Conditions of Participation are officially published in the:
A. Journal of American Hospital Association
B. Joint Commission of Accreditation of Healthcare Organizations Manual for Hospitals
C. Federal register
C. Federal register
126
Which type of hospital board consists of non-paid individuals who contribute their time and expertise in the interest of service to the facility or to the community?
A. Philanthropic
B. Corporate
C. Board-in-residence
A. Philanthropic
127
Mind-body interventions, biologically based treatments, manipulative and body-based methods, and energy therapies are all examples of:
A. Conventional medicine
B. Alternative or complimentary medicine
C. Physician privileging categories
B. Alternative or complimentary medicine
128
Which term describes skilled and intermediate nursing facilities, hospice programs, community mental health centers, and home health care systems that are designed to provide needed services in a manner that is more cost effective than a hospital?
A. Alternative delivery systems
B. Skilled care systems
C. Managed care
A. Alternative delivery systems
129
Which term describes an organization which reviews services provided under the Medicare program to determine whether a hospital has misrepresented admission or discharge information or has taken an action that results in the unnecessary admission of an individual entitled to benefits under Medicare Part A?
A. National Committee on Quality Assurance
B. Joint Commission on Accreditation of Healthcare Organizations
C. Peer Review Organization
C. Peer Review Organization
130
Which term describes programs providing palliative care and emotional and physical support to terminally ill patients and their families, generally during the last six months of the patient's life in the patient's home?
A. Health maintenance organization
B. Long term care facility
C. Hospice
C. Hospice
131
Which body acts for the medical staff as a whole, and makes recommendations to the governing body with regard to medical staff issues?
A. Medical staff peer review committee
B. Governing body
C. Medical Executive Committee
C. Medical Executive Committee
132
You go to the file cabinet and pick out 20 files for audit. This type of sample is called:
A. A cluster sample
B. A self-selected sample
C. A simple random sample
C. A simple random sample
133
What is the name of the data collection developed by the Centers for Medicare and Medicaid Services to improve outcomes of patient care and to ensure that they receive the best health care available?
A. Core Measures
B. Uniform Patient Discharge Data Set
C. Medicare/Medicaid Patient Discharge Data Set
A. Core Measures
134
When a proctor visits a hospital nursing station to review inpatient health records, this is called:
A. Retrospective review
B. Concurrent review
C. Discharge analysis
B. Concurrent review
135
In any computerized data collection system:
A. There is too much data collected to provide accurate reporting mechanisms
B. Computerized information processing requires quality control checks to be performed
C. There is never enough data collected to provide optimal reliability in computations
B. Computerized information processing requires quality control checks to be performed
136
Which graphical presentation type always depicts percentages?
A. Bar graph
B. Pie chart
C. Histogram
B. Pie chart
137
A person against whom an action is brought in a lawsuit is the:
A. Appellee
B. Plaintiff
C. Defendant
C. Defendant
138
What a reasonably prudent person would have done under similar circumstances is termed the:
A. Duty of the provider
B. Standard of care
C. Patient-physician privilege
B. Standard of care
139
The party who commences a lawsuit is the:
A. Defendent
B. Appellant
C. Plaintiff
C. Plaintiff
140
In order to verify HIPAA security provisions are met, an organization should have a:
A. Chain-of-Trust Partner Agreement
B. Business Continuity Plan
C. Information Access Control Plan
C. Information Access Control Plan
141
According to the Medicare Conditions of Participation for Hospitals, criteria for selection to the medical staff must include individual competence, training, experience, judgement, and:
A. Character
B. Ability to perform the procedures requested
C. Board certification
A. Character
142
Which statement is characteristic of a group practice?
A. It consists of a single specialty or multi specialty and provides comprehensive care
B. It has management responsibility for providing comprehensive prepaid patient care
C. It is an organized outpatient department physically separate from the hospital
A. It consists of a single specialty or multi specialty and provides comprehensive care
143
Which is an example of what would be included in a medical staff rule and regulation?
A. Description of the medical staff organization including leadership
B. Description of how members are appointed to the emergency room call schedule
C. Qualifications for medical staff membership
B. Description of how members are appointed to the emergency room call schedule
144
Compliance by a hospital with which of the following would be considered voluntary?
A. ACHC standards
B. Medicare Conditions of Participation
C. State hospital licensing regulations
A. ACHC standards
145
According to the DNV, a history and physical completed within 30 days prior to admission or registration shall include an entry in the medical record which documents an examination for any change in the patient's current medical condition and placed in the patient's medical record within what timeframe?
A. Within 48 hours prior to the admission or registration
B. Immediately upon admission or registration, but prior to surgery or high risk procedures
C. Within 24 hours after admission or registration, and prior to surgery or procedures requiring anesthesia services
C. Within 24 hours after admission or registration, and prior to surgery or procedures requiring anesthesia services
146
A departmentalized medical staff is organized according to service. What is the title of the medical staff leader who is responsible for directing the functions of each service?
A. Chairperson
B. Supervisor
C. Coordinator
A. Chairperson
147
Automatic suspension of clinical privileges may be considered at a DNV accredited hospital for the following instances:
A. Providing an incomplete application; not disclosing three professional references
B. Revocation/restriction of professional license; non-compliance with completing medical records
C. Revocation/restriction of professional license; non-compliance in attending all medical staff meetings and not utilizing all clinical privileges granted
B. Revocation/restriction of professional license; non-compliance with completing medical records
148
In selecting a new information system, the primary consideration should be the:
A. Cost of the system
B. Requirements of the user
C. Available technology
C. Available technology
149
According to the DNV, if the medical staff has an executive committee, who must attend the meeting?
A. Medical staff members and CEO
B. Medical staff members only
C. Medical staff members, CEO and CNO (or designee) on an ex-officio basis
C. Medical staff members, CEO and CNO (or designee) on an ex-officio basis
150
Information is:
A. Less complex than data
B. Part of data
C. Compiled from data
A. Less complex than data
151
In addition to the Chief Executive Officer, what medical staff authority is required for granting temporary privileges?
A. Medical Executive Committee
B. Member of the Medical Executive Committee, President of the Medical Staff, or Medical Director
C. President of the Medical Staff
C. President of the Medical Staff
152
A system that shows who has accessed what information in a computer system, such as a patient registration database, is called a(an):
A. Audit trail
B. Smart card
C. Access point
A. Audit trail
153
Which term most accurately defines programs designed to control liability for human errors and equipment failures?
A. Utilization review/management programs
B. Quality management programs
C. Risk management programs
C. Risk management programs
154
According to Joint Commission standards, relevant findings from quality management activities must be considered as part of the:
A. Reappointment of clinical privileges of medical staff members
B. Selection or election of medical staff officers
C. Renewal of contracts with phyisicians
A. Reappointment of clinical privileges of medical staff members
