CPCS Ongoing Monitoring and Audits 3 — Questions and Answers
Question 1: During an internal credentialing audit, reviewers find that 15% of provider files lack current immunization records as required by policy. What type of finding is this?
- A sentinel event
- A compliance gap requiring a corrective action plan (Correct answer)
- An FPPE trigger
- A grounds for immediate termination of all affected providers
Correct answer: A compliance gap requiring a corrective action plan
A systemic gap identified in an audit requires a corrective action plan to remediate the deficiency and prevent recurrence.
Question 2: A credentialing manager is designing an audit tool to evaluate file completeness. Which element is most critical to include for ongoing monitoring compliance?
- Provider's personal references from five years ago
- Expiration dates of all time-limited credentials (Correct answer)
- Date the provider first applied for privileges
- Copy of the original application form
Correct answer: Expiration dates of all time-limited credentials
Tracking expiration dates of licenses, certifications, and insurance policies is essential to proactive ongoing monitoring.
Question 3: Which accreditation standard specifically requires hospitals to have a process for ongoing monitoring of licensed independent practitioners' competency?
- CMS Conditions of Participation, §482.12
- The Joint Commission MS.08.01.01 (Correct answer)
- NCQA Credentialing Standard CR 11
- URAC Standard CVO 3-1
Correct answer: The Joint Commission MS.08.01.01
TJC standard MS.08.01.01 addresses OPPE and requires a defined process for ongoing review of practitioner performance.
Question 4: A peer review committee flags a surgeon for an unusually high complication rate. Under OPPE requirements, what should happen next?
- Automatic revocation of surgical privileges
- Initiation of FPPE to evaluate the specific concerns in a structured manner (Correct answer)
- Referral directly to the state medical board
- Mandatory 30-day leave of absence
Correct answer: Initiation of FPPE to evaluate the specific concerns in a structured manner
OPPE data triggering concern leads to FPPE, a time-limited focused evaluation designed to assess the specific performance issue.
Question 5: How does ongoing monitoring of provider sanctions differ from the initial credentialing verification process?
- Ongoing monitoring uses primary source verification; initial credentialing does not
- Ongoing monitoring occurs continuously between credentialing cycles; initial credentialing is a one-time review (Correct answer)
- Ongoing monitoring only applies to employed providers; initial credentialing covers all applicants
- There is no functional difference between the two processes
Correct answer: Ongoing monitoring occurs continuously between credentialing cycles; initial credentialing is a one-time review
Ongoing monitoring is a continuous process that occurs between formal recredentialing cycles, while initial credentialing is a discrete one-time review of a new applicant.
Question 6: An organization subscribes to an automated exclusion screening service that checks the OIG LEIE daily. A match is returned for a nurse practitioner. What is the FIRST step?
- Immediately terminate the NP's employment
- Verify the match is the correct individual before taking action (Correct answer)
- Report the finding to the NPDB within 30 days
- Notify the state nursing board immediately
Correct answer: Verify the match is the correct individual before taking action
False positives occur due to common names, so the identity must be confirmed before any adverse action is taken.
Question 7: What is the recommended best practice for documenting the results of ongoing monitoring activities in a provider's credentials file?
- Document only findings that result in corrective action
- Maintain a running log with dates, sources checked, and outcomes for all monitoring activities (Correct answer)
- Store monitoring results in a separate system not linked to the credentials file
- Document monitoring results only at the time of formal recredentialing
Correct answer: Maintain a running log with dates, sources checked, and outcomes for all monitoring activities
A comprehensive, date-stamped audit trail of all monitoring activities demonstrates due diligence and supports accreditation surveys.
CPCS Ongoing Monitoring and Audits 3
During an internal credentialing audit, reviewers find that 15% of provider files lack current immunization records as required by policy.
What type of finding is this?