CPCS Ongoing Monitoring and Audits 2 — Questions and Answers
Question 1: Which federal database must credentialing organizations query as part of ongoing monitoring to identify providers with adverse actions against their Medicare/Medicaid participation?
- NPDB
- OIG List of Excluded Individuals and Entities (Correct answer)
- FSMB DocInfo
- CMS Provider Enrollment Chain
Correct answer: OIG List of Excluded Individuals and Entities
The OIG List of Excluded Individuals and Entities (LEIE) must be checked to ensure providers have not been excluded from federal healthcare programs.
Question 2: A hospital's medical staff office discovers mid-cycle that a physician's Drug Enforcement Administration (DEA) registration expired three weeks ago. What is the immediate required action?
- Notify the department chief and restrict the physician from prescribing controlled substances (Correct answer)
- Wait until the next recredentialing cycle to address the lapse
- Automatically terminate the physician's privileges
- File a report with the NPDB immediately
Correct answer: Notify the department chief and restrict the physician from prescribing controlled substances
An expired DEA registration must trigger immediate restriction of controlled substance prescribing privileges until the registration is renewed.
Question 3: What term describes the process of reviewing a provider's performance data, complaints, and licensure status between full recredentialing cycles?
- Provisional credentialing
- Focused Professional Practice Evaluation (FPPE)
- Ongoing Professional Practice Evaluation (OPPE) (Correct answer)
- Credentials verification
Correct answer: Ongoing Professional Practice Evaluation (OPPE)
OPPE is the continuous review of practitioner performance data used to inform decisions about maintaining, modifying, or revoking privileges.
Question 4: When conducting ongoing monitoring, how frequently does The Joint Commission recommend that organizations review OPPE data for licensed independent practitioners?
- Annually only
- At least every 12 months but organizations may set shorter intervals (Correct answer)
- Every 24 months to align with recredentialing
- Only when a complaint is received
Correct answer: At least every 12 months but organizations may set shorter intervals
TJC requires OPPE data be reviewed at defined intervals that must not exceed 12 months, though organizations may review more frequently.
Question 5: A credentialing specialist receives an automated alert that a practitioner's malpractice insurance policy will lapse in 10 days. Which action reflects best practice?
- Wait for the practitioner to self-report the renewal
- Immediately suspend the practitioner's privileges
- Contact the practitioner and require proof of renewed coverage before the lapse date (Correct answer)
- Note the lapse in the file and address it at recredentialing
Correct answer: Contact the practitioner and require proof of renewed coverage before the lapse date
Proactive outreach to require proof of renewed coverage before a lapse protects the organization and maintains continuous compliance.
Question 6: Which of the following best describes a 'watch list' in the context of credentialing ongoing monitoring?
- A list of providers eligible for expedited privileges
- A confidential internal list of providers requiring heightened scrutiny due to performance concerns (Correct answer)
- A roster of providers whose recredentialing is due within 90 days
- A publicly accessible registry of disciplined practitioners
Correct answer: A confidential internal list of providers requiring heightened scrutiny due to performance concerns
A watch list is an internal tool used to flag practitioners who need closer monitoring due to quality concerns, complaints, or adverse events.
Question 7: What is the primary purpose of conducting a sanctions screening against the SAM (System for Award Management) database during ongoing monitoring?
- To verify board certification status
- To identify providers debarred from federal contracts and programs (Correct answer)
- To confirm state licensure is active
- To review malpractice history
Correct answer: To identify providers debarred from federal contracts and programs
SAM.gov lists individuals and entities debarred or suspended from participation in federal contracts, grants, and programs.
CPCS Ongoing Monitoring and Audits 2
Which federal database must credentialing organizations query as part of ongoing monitoring to identify providers with adverse actions against their Medicare/Medicaid participation?