Study Session 2/18/2025

Question 1

Established in 1956, an organization that assesses whether international medical graduates are ready to enter residency or fellowship programs in the United States.

Answer 1

ECFMG

Question 2

National non-profit organization that represents the 71-state medical and osteopathic boards of the U.S. and its territories and co-sponsors the USMLE.

Answer 2

FSMB

Question 3

Containing information on medical malpractice payments and certain adverse actions related to health care practitioners, providers and suppliers.

Answer 3

NPDB

Question 4

Database that contains information about people and entities in the healthcare field who have been involved in fraud, abuse or other wrongdoings.

Answer 4

FACIS

Question 5

Founded in 1847, Established to promote the art and science of medicine and the betterment of public health.

Answer 5

AMA

Question 6

This organization requires a process by which an organization reviews and evaluates qualifications of licensed practitioners’ to provide services to its members

Answer 6

NCQA

Question 7

Sets and monitors voluntary professional education standards essential in preparing physicians to deliver safe, high-quality medical care.

Answer 7

ACGME

Question 8

_____________is a code of rules and ethics for working together in groups.

a. Parliamentary Procedure
b. Quorum
c. Incidental motion

Answer 8

Parliamentary Procedure

Question 9

The organization must verify the most recent 5- year period available for sanctions or limitations on any state licensure held (past and present).

a. NCQA
b. URAC
c. ACHC

Answer 9

NCQA

Question 10

If there is no provision regarding a quorum in the bylaws, what provides that a majority of members constitutes a quorum?

a. Common law
b. Robert’s Rules of Order
c. applicable Federal, State, or local laws

Answer 10

Common law

Question 11

__________credentialing reduces or eliminates duplication of verifications thus increasing productivity and decreasing cost?

a. Internal
b. Centralized
c. Delegation / External

Answer 11

Centralized

Question 12

__________ states that at least the past five-year history of professional liability actions resulting in final settlements or judgments must be evaluated. Malpractice litigation history (final judgments and settlements) is received from insurance carrier or NPDB.

a. TJC
b ACHC
c. DNV

Answer 12

ACHC

Question 13

Information on medical school graduation verified directly with the medical school is considered:

a. Secondary Source
b. Designated Equivalent Source
c. Primary Source

Answer 13

Primary Source

Question 14

“I move to postpone the motion to…” is what type of motion?

a. Privileged
b. Subsidiary
c. Incidental

Answer 14

Subsidiary

Question 15

Releasing information incurs a substantial liability. In addition to making sure that accurate information is provided, what else must be done?

a.Evaluate the legal climate in their area and draft policies regarding the release of information.
b. Make sure they are releasing information to individuals authorized to request the information.
c. Send back with note stating “the release does not reference your organization.”

Answer 15

Make sure they are releasing information to individuals authorized to request the information.

Question 16

The types of information reported to the ______ includes medical malpractice payments (for all healthcare practitioners), adverse licensure actions, clinical privileging actions and professional society membership actions, as well as negative actions or findings and Medicare exclusions?

a. ABMS
b. AMA
c. NPDB

Answer 16

NPDB

Question 17

DNV States the following in regard Licensure / License Sanctions:

a. Verify current state license on an ongoing basis; at a minimum, at expiration, appointment and re-appointment. Verify from primary or secondary source
b. There must be verification of licensure or certification as minimally required to engage in clinical practice directly from the State board
c. MS bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate. Those qualifications shall include primary source verification of current licensure on initial appointment and reappointment. Sanctions not specifically addressed

Answer 17

MS bylaws describe the qualifications to be met by a candidate in order for the medical staff to recommend that the governing body appoint the candidate. Those qualifications shall include primary source verification of current licensure on initial appointment and reappointment. Sanctions not specifically addressed

Question 18

PSV can be performed in several ways.

a. Letter requesting information
b. Via mail, email , fax, or telephone
c. All the above

Answer 18

All the above

Question 19

Organizations must have processes in place to ensure that credentials file are accessed only by authorized staff. Requirements for storage, maintenance and disposal of credentialing documents must also be defined.

a. NCQA
b. Medicare
c. URAC

Answer 19

URAC

Question 20

Which standard states the medical staff bylaws or credentials manual must indicate the requirements for the hospital to verify the licensure, certifications, education and training, post graduate experiences, and other references from primary sources whenever possible

a. NCQA
b. ACHC
c. AAAHC

Answer 20

ACHC

Question 21

Which 2 have requirements for Database Controls?

a. URAC and NCQA
b. DNV and TJC
c. AAAHC and ACHC

Answer 21

URAC and NCQA

Question 22

What is the purpose of Subsidiary motions?

a. Assist the body in considering or disposing of a main motion.
b. Do not relate to the pending business but have to do with special matters of immediate importance that should be allowed to interrupt the consideration of anything else.
c. Deal with questions of procedure arising out of other motions or business

Answer 22

Assist the body in considering or disposing of a main motion.

Question 23

Which accreditor says: MS 6 SR 5(c) Review of involvement in any professional liability action is required at initial and reappointment

a. Medicare
b. TJC
c. DNV

Answer 23

DNV

Question 24

AMA Physician Masterfile data meets select credentialing requirements for all standards except for one.

a. TJC
b. Medicare
c. NCQA

Answer 24

NCQA

Question 25

_________ motions do not relate to the pending business but have to do with special matters of immediate importance that should be allowed to interrupt the consideration of anything else? a. Privileged b. Subsidiary c. Main

Answer 25

Privileged

Question 26

When it is not possible to obtain the information from a primary source, like when a hospital is closed. When applicant records have been lost or destroyed. When applicant received education in a foreign country and verification information is not accessible, are examples of ________ ___________ a. Primary Source b. Designated Equivalent Source c. Secondary Source

Answer 26

Secondary Source

Question 27

Which Regulatory agency restricts the ability of incompetent physicians, dentists, and other health care practitioners who move from state to state without disclosure or discovery of previous medical malpractice payment and adverse action history. a. FSMB b. NPDB c. Medicare

Answer 27

NPDB

Question 28

This standard states that organizations are responsible for the ongoing monitoring of sanctions or limitations on licensure between recredentialing cycles. a. TJC b. NCQA c. URAC

Answer 28

NCQA

Question 29

Who states that a cover sheet or attestation from the insurance company is sufficient to prove attainment of liability coverage? a. URAC b. NCQA c. AAAHC

Answer 29

URAC

Question 30

___________is the original issuing entity of a specific credential that can verify the accuracy of the credential reported by an individual health care practitioner. Primary source verification (PSV) is received directly from the issuing source. For example, if information on medical school graduation is verified directly with the medical school, this is considered PSV. A copy of the medical school diploma is not considered PSV. a. Primary Source b. Secondary Source c. Designated Equivalent Source

Answer 30

Primary Source

Question 31

Must have evidence of professional liability insurance including current certificates showing amount insurance; malpractice litigation history from insurance carrier. a. TJC b. DNV c. ACHC

Answer 31

ACHC

Question 32

Two standards state that the past 5-year history of professional liability must be either verified or evaluated. Who are they? Bonus: Which standard says verified and which says evaluated? a. NCQA and ACHC b. NCQA and URAC c. ACHC and AAAHC

Answer 32

NCQA and ACHC

Question 33

What are the precedence of motions? a. Main motion, Subsidiary motion, Privilege motion b. Privilege motion, Subsidiary motion, Main motion c. Subsidiary motion, Main motion, Privilege motion

Answer 33

Privilege motion, Subsidiary motion, Main motion

Question 34

In certain cases, _________ allows the use of other reliable secondary sources, such as another hospital that has documented PSV of the applicant’s credentials. Prior to using such sources, an attempt must be made to contact the primary source. This attempt should be documented by keeping the returned letters or by documenting the letters that were sent with no response. a. AAAHC b. NCQA c. TJC

Answer 34

TJC

Question 35

If the use of a reliable secondary source is used, such as another hospital that has documented PSV of the applicant's credentials, what must be done prior to using such sources? a. An attempt must be made to contact the primary source and the practitioner should be notified. b. An attempt must be made to contact the primary source and the attempt should be documented. c. An attempt must be made to contact the primary source, but no further action required

Answer 35

An attempt must be made to contact the primary source and the attempt should be documented

Question 36

Which data bank is the official government-wide system of records of debarments, suspension and other exclusionary actions? a. OIG b. NPDB c. SAM

Answer 36

SAM

Question 37

Who states that changes made to credentialing information must be tracked and the organization must document when and how the data was changed, who made the change and why the change was made? a. TJC b. URAC c. NCQA

Answer 37

NCQA

Question 38

What kind of motion has no order of precedence, arises incidentally and decided immediately? a. Incidental motion b. Main motion c. Privileged motion

Answer 38

Incidental motion

Question 39

Who allows the use of the FACIS for licensure/licensure sanctions verifications? a. ACHC b. NCQA c. URAC

Answer 39

ACHC

Question 40

Which accreditation states that practitioners with federal tort coverage, the practitioner file can include a copy of the federal tort letter or an attestation from the practitioner of federal tort coverage? a. NCQA b. DNV c. TJC

Answer 40

NCQA

Question 41

Which accreditation states that before recommending privileges, the medical staff evaluates any evidence of an unusual pattern or an excessive number of professional liability actions resulting in a final judgment against the applicant? a. TJC b. AAAHC c. DNV

Answer 41

TJC

Question 42

Which of the following statements accurately describes Primary Source Verification?​​ a. A copy of a medical school diploma is considered Primary Source Verification​​ b. Primary Source Verification can be done through methods such as mail, email, fax, or telephone, with the responses received directly from the issuing source​​ c. Secondary sources are always acceptable for verifying credentials if the primary source is unavailable​​

Answer 42

Primary Source Verification can be done through methods such as mail, email, fax, or telephone, with the responses received directly from the issuing source​​

Question 43

Which accrediting body can use the results from a search of the FSMB Disciplinary Action Databank or FACIS? a. TJC b. DNV c. ACHC

Answer 43

ACHC

Question 44

Not addressed, however, if the medical staff bylaws, rules and regulations require malpractice coverage, it is expected that the accrediting body have a method to verify such coverage. a. Medicare b. TJC c. DNV

Answer 44

TJC

Question 45

The application includes information regarding professional liability claims history and is reviewed at initial and reappointment. a. DNV b. URAC c. AAAHC

Answer 45

AAAHC

Question 46

What is considered an acceptable reliable secondary source verification by TJC? a. Documented verbal verification b. Physical copy of document c. Another hospital that has documented PSV of the applicant’s credentials

Answer 46

Another hospital that has documented PSV of the applicant’s credentials

Question 47

Which accreditation standards have requirements regarding data base controls? a. ACHC and TJC b. NCQA and URAC c. Medicare, DNV, and AAAHC

Answer 47

NCQA and URAC

Question 48

Various types of entities are required to report adverse actions to the NPDB. Which one of the organizations listed below is not an example of a required reporting entity? a. State Medicaid Fraud Control Units b. HHS OIG c. State licensing and certification boards

Answer 48

State Medicaid Fraud Control Units

Question 49

What motions can be amended? a. Postpone to a certain time (I move to postpone motion to …) b. Lay aside temporarily (I move to lay the question on the table) c. Submit matter to assembly (I appeal from the decision of the chair)

Answer 49

Postpone to a certain time (I move to postpone motion to …)

Question 50

Which accreditation standards requires verification of the past five-year history of professional liability claims resulting in settlements or judgements? a. NCQA, DNV, and URAC b. ACHC and NCQA c. Medicare, AAAHC, NCQA, and ACHC

Answer 50

ACHC and NCQA

Question 51

NCQA requires that the license must be confirmed within a certain time limit of the credentialing decision. What is the time frame? a. 180 days b. 60 days c. 180 days (MCO); 120 days (CVO)

Answer 51

180 days (MCO); 120 days (CVO)

Question 52

What are the 3 major approaches to verification? a. Internal, External / Delegated, and Centralized b. Centralized, Database, and Company / External c. Primary, Secondary, and Designated Equivalent Source

Answer 52

Internal, External / Delegated, and Centralized

Question 53

All of these "Red Flags" would be reportable to NPDB except for _______. a. Adverse licensure action b. Malpractice payments c. Non-compliance of residency

Answer 53

Non-compliance of residency

Question 54

What refers to maintaining and assuring the accuracy and consistency of data over its life-cycle to make sure that data will always be correct, consistent and accessible? a. Database audits b. Data integrity c. Data preservation

Answer 54

Data integrity

Question 55

When you want to limit or extend a debate you stay? a. Let's take this offline b. I move that debate to be limited or extended c. I move to refer the motion

Answer 55

I move that debate to be limited or extended

Question 56

FSMB is recognized as a designated equivalent source for licensure sanctions with this accreditation? a. TJC b. NCQA c. URAC

Answer 56

TJC

Question 57

Attestation of malpractice coverage by the practitioner is not acceptable by this accreditor? a. URAC b. TJC c. NCQA

Answer 57

URAC

Question 58

What is the time frame of verification for NCQA and the malpractice history? a. 7-10 years b. 36 months c. 5 years

Answer 58

5 years

Question 59

__________ requires specific credentials to be verified within six months of the decision as outlined in the section Primary Source Verification of credentials. a. TJC b. AAAHC c. URAC

Answer 59

URAC

Question 60

NPDB querying entities include: a. Hospitals and Healthcare entities b. Professional societies with formal peer review c. All of the above

Answer 60

All of the above

Question 61

Name one organization that has requirements regarding database controls. a. NCQA b. Medicare c. TJC

Answer 61

NCQA

Question 62

A ____________ is the number or proportion of the members that must be present in order to transact business. a. Judicial entity b. Executive Body c. Quorum

Answer 62

Quorum

Question 63

Must confirm that the practitioner holds a valid, current license, in effect at the time of the Credentialing Committee’s decision. Only required to verify license(s) in the state(s) where the practitioner provides care for organization members. Verification must be obtained directly from the state licensing agency or its website. a. DNV b. Medicare c. NCQA

Answer 63

NCQA

Question 64

Professional liability coverage not addressed. However, if the medical staff bylaws/ rules/ regulations require malpractice coverage, it is expected that the organization have a method to verify such coverage. a. AAAHC b. TJC c. DNV

Answer 64

TJC

Question 65

Malpractice/Professional Liability Time limit: must be verified within 180 days (MCO) / 120 days (CVO) of the credentialing decision. a. TJC b. NCQA c. Medicare

Answer 65

NCQA

Question 66

Which accreditation requires specific credentials to be verified within six months of the decision as outlined in the section primary source verification of credentials? a. ACHC b. DNV c. URAC

Answer 66

URAC

Question 67

Which standards do not have any requirements regarding date base controls? a. TJC, DNV and NCQA b. TJC, DNV and URAC c. TJC, DNV, ACHC, AAAHC, and Medicare

Answer 67

TJC, DNV, ACHC, AAAHC, and Medicare

Question 68

Not every motion can be made at any given time. Rather, motion are proposed, considered, and disposed of in a priority of order known as? a. Precedence b. Incidental c. Privileged

Answer 68

Precedence

Question 69

According to Medicare CoPs, the governing body must ensure that the criteria for selection of medical staff are? a. As out lined by medical staff bylaws b. Character, competence, judgement, experience & training c. Competence, capability, education, proficiency & abilities

Answer 69

Character, competence, judgement, experience & training

Question 70

Per __________ information must be reviewed within 30 days of release by the reporting entity. a. NCQA b. URAC c. AAAHC

Answer 70

NCQA

Question 71

Many organizations undertake credentials verification internally where the organization’s staff verifies all information from the primary and/or approved sources. This is referencing what type of verification? a. External b. Internal c. Centralized

Answer 71

Internal

Question 72

When an organization enrolls its providers in the continuous query, that organization receives a notification within how many hours of a report received by the NPDB? a. 24 hours b. 72 hours c. 12 hours

Answer 72

24 hours

Question 73

PDC reports also provide information pertaining to: a. Licensure history and biographical information b. Education and training, and national identification numbers (when available) c. All of the above

Answer 73

All of the above

Question 74

The following organizations do not have any requirements regarding database controls: a. Medicare, TJC, ACHC, DNV, and AAAHC b. Medicare, DNV, TJC, NCQA, and URAC c. Medicare, ACHC, DNV, and AAAHC

Answer 74

Medicare, TJC, ACHC, DNV, and AAAHC

Question 75

All actions in a meeting are initiated by what? a. Motions b. The chairman of the board c. A majority vote

Answer 75

Motions

Question 76

According to this organization, the FSMB is recognized as a designated equivalent source for information regarding licensure actions. a. DNV b. TJC c. AAAHC

Answer 76

TJC

Question 77

These two organizations do NOT specifically address malpractice insurance or professional liability coverage. a. AAAHC, URAC b. ACHC, DNV c. TJC, Medicare

Answer 77

TJC, Medicare

Question 78

These two organizations require the application contain information pertaining to malpractice / professional liability history. a. AAAHC, URAC b. ACHC, DNV c. TJC, Medicare

Answer 78

AAAHC, URAC

Question 79

Email notifications are received within ____________of a reporting being received by NPDB on a practitioner. a. 48 hours b. 180 days c. 24 hours

Answer 79

24 hours

Question 80

TJC identifies ______ acceptable designated sources. a. 3 b. 6 c. 7

Answer 80

7

Question 81

NCQA mentions __________ require that the organization has implemented mechanisms that guard against unauthorized access to and modification of credential files. a. CVO standards b. MEC c. MCO

Answer 81

CVO standards

Question 82

“I move to adjourn” is a statement that reflects a _______. a. Subsidiary motion b. Main motion c. Privileged motion

Answer 82

Privileged motion

Question 83

Which accrediting organization mentions MS 6 Interpretive Guidelines that state medical staff bylaws shall provide a mechanism for consideration of automatic suspension of clinical privileges in instances of revocation/restriction of professional license. a. ACHC b. TJC c. DNV

Answer 83

DNV

Question 84

__________ states that a cover sheet or attestation from the insurance company is sufficient to prove attainment of liability coverage. a. URAC b. DNV c. TJC

Answer 84

URAC

Question 85

Some hospitals and managed care organizations ______________ the PSV process to a credentials verification organization (CVO), an organization that collects and verifies information and forwards it to the entity that is contracted for the service. a. Request b. Delegate c. Copy

Answer 85

Delegate

Question 86

According to the _________, its primary objective is to improve the quality of health care by encouraging state licensing boards, hospitals, professional societies, and other health care entities to identify and discipline those who engage in unprofessional behavior. a. FSMB b. NPDB c. OIG

Answer 86

NPDB

Question 87

What are the 2 accreditation organizations that address credentialing system controls? a. NCQA and URAC b. TJC and ACHC c. ACHC and AAAHC

Answer 87

NCQA and URAC

Question 88

All actions in a meeting are initiated by ____________. a. The Committee Chair b. Motions c. CEO or CMO

Answer 88

Motions

Question 89

What accreditation standard states that you are only required to verify a license(s) in the state/s where the practitioner provides care for the organization members? a. URAC b. Medicare c. NCQA

Answer 89

NCQA

Question 90

What accreditation standard states MS 6 Interpretive Guidelines state that the medical staff criteria for consideration of automatic suspension, summary suspension, and includes when the practitioner has failed to maintain the minimum specified amount of professional liability insurance as required in the medical staff bylaws? a. NCQA b. DNV c. TJC

Answer 90

DNV

Question 91

What accreditation standard states that before recommending privileges, the medical staff must evaluate any evidence of an unusual pattern(s) resulting in a final judgement against the applicant? a. TJC b. DNV c. ACHC

Answer 91

TJC

Question 92

Endometriosis: a condition in which tissue similar to the lining of the uterus (endometrium) grows outside of the uterus

Answer 92

Gynecologist Primary Care Provider

Question 93

Fluoroscopy: an X-ray procedure that allows doctors to see internal organs in motion. It uses a fluoroscope, which is a tube or box with a fluorescent screen. The screen is coated with a fluorescent substance that allows doctors to see X-rays or other radiation

Answer 93

Radiologist; Radiologic technologist Cardiologists (for cardiac catheterization)  Gastroenterologists (for upper GI studies)  Orthopedic surgeons (for guided orthopedic procedures)  Physician Assistants (with appropriate training and supervision) 

Question 94

Kyphoscoliosis: a condition that caused both a hunchback and a sideways curvature of the spine, leading to significant discomfort and mobility issues.

Answer 94

Orthopedic Surgeon Physical Medicine & Rehabilitation Radiology; Radiologist Neurosurgeon