Ongoing Monitoring and Audits Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Ongoing Monitoring and Audits flashcards as text
Under NCQA credentialing standards, how frequently must a health plan re-credential its network providers?
Answer: Every three years
NCQA standards require health plans to recredential network practitioners at least every three years.
A credentialing coordinator notices that a provider's malpractice carrier has downgraded the policy limits below the organization's minimum threshold. Under ongoing monitoring, what is the CORRECT response?
Answer: Notify the provider and require evidence of coverage meeting the minimum threshold within a defined timeframe
When coverage falls below minimum thresholds, the provider must be notified and given a defined window to remedy the deficiency before privileges are affected.
Which of the following best describes the concept of 'continuous monitoring' in modern credentialing programs?
Answer: Using automated, real-time or near-real-time alerts from databases to flag credential changes as they occur
Continuous monitoring uses automated database connections to generate alerts when licensure, exclusion, or sanction data changes, enabling immediate response.
A hospital's credentials committee receives an OPPE report showing a hospitalist's mortality rate is a statistical outlier. The committee must take action under which principle?
Answer: The corporate negligence doctrine requiring hospitals to monitor and act on known competency concerns
The corporate negligence doctrine holds hospitals directly liable for failing to act on known practitioner competency concerns identified through monitoring.
When performing an ongoing monitoring audit, a credentialing specialist finds that a provider who lists a DEA registration has a specialty inconsistent with controlled substance prescribing. What is the best next step?
Answer: Flag the inconsistency for medical staff leadership review to determine if the DEA registration is clinically appropriate for the granted privileges
Clinical appropriateness of credentials relative to granted privileges is a medical staff leadership determination, not a unilateral credentialing staff decision.
Which type of credentialing audit assesses whether the organization's own credentialing policies and procedures conform to accreditation standards?
Answer: Standards compliance audit
A standards compliance audit evaluates whether the organization's policies, procedures, and practices align with the requirements of its accrediting body.
A credentialing program implements a 90-60-30 day expiration tracking system. What is the primary benefit of the 90-day advance alert?
Answer: It provides sufficient lead time to resolve complex renewals before a credential lapses, preventing privilege suspension
A 90-day advance alert allows adequate time to address complex renewals such as board recertification or state licensure that may involve lengthy processes.