CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers Flashcards
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How frequently must organizations participating in the Medicare and Medicaid programs check practitioners against the OIG List of Excluded Individuals/Entities (LEIE)?
Answer: At least monthly, per OIG guidance
The OIG recommends that healthcare organizations check the LEIE at least monthly to ensure no currently participating practitioners or employees are excluded from federal healthcare programs.
During a credentialing audit, a surveyor finds that OPPE reports have not been provided to practitioners at any point during the past 18 months. Under TJC standards, this would be considered which type of deficiency?
Answer: A Requirement for Improvement (RFI)
Failure to conduct OPPE at the required interval (at least every 6 months) would be cited as a Requirement for Improvement under TJC standards, requiring submission of an Evidence of Standards Compliance.
An organization is implementing continuous monitoring for its practitioner network. Which database should be checked to identify practitioners who have had DEA registration revoked or surrendered?
Answer: The DEA Diversion Control Division website
DEA registration actions (revocation, suspension, surrender) can be verified through the DEA Diversion Control Division website or by contacting the DEA directly, in addition to NPDB which also receives DEA adverse action reports.
What is the primary purpose of conducting a 'focused audit' of credentialing files?
Answer: To identify specific compliance gaps or areas needing improvement in the credentialing process
Focused audits target specific elements or processes in the credentialing program to identify compliance gaps, assess adherence to policies, and identify areas for process improvement.
A credentialing manager is developing a quality dashboard for the credentialing program. Which of the following metrics would best measure the efficiency of the initial credentialing process?
Answer: Average number of days from completed application receipt to committee approval
Average processing time from completed application to committee approval directly measures the efficiency of the initial credentialing workflow and can be benchmarked against industry standards and accreditation requirements.
An organization's recredentialing audit reveals that 8% of practitioners have not been sent recredentialing letters within the policy-required timeframe. This finding should be addressed through which quality improvement mechanism?
Answer: A root cause analysis to identify why the timing requirement is not being met, followed by process correction
A systematic process failure (8% non-compliance with policy) should be addressed through root cause analysis to identify why the process is failing, followed by targeted process improvements.