CPCS Ongoing Monitoring and Audits 4 — Questions and Answers
Question 1: A credentialing audit reveals that a practitioner's board certification lapsed 14 months ago and the provider did not self-report. What policy violation does this most directly represent?
- Failure to maintain continuing medical education requirements
- Breach of the self-reporting obligation outlined in the medical staff bylaws (Correct answer)
- A HIPAA privacy violation
- Grounds for an automatic NPDB report
Correct answer: Breach of the self-reporting obligation outlined in the medical staff bylaws
Medical staff bylaws universally require practitioners to self-report changes in credentials status; failure to do so is a bylaw violation.
Question 2: Which of the following metrics would be LEAST useful as an OPPE indicator for an emergency medicine physician?
- Door-to-physician time
- Patient satisfaction scores specific to ED encounters
- Surgical site infection rates (Correct answer)
- Left without being seen rates attributed to the provider
Correct answer: Surgical site infection rates
Surgical site infection rates are not applicable to emergency medicine physicians who do not perform surgery in that role.
Question 3: What is the primary regulatory driver requiring Medicare-participating hospitals to conduct ongoing monitoring of provider exclusion status?
- State Department of Health licensing requirements
- CMS Conditions of Participation requiring hospitals not to employ or contract with excluded individuals (Correct answer)
- The Joint Commission standard LD.04.01.01
- HIPAA Security Rule requirements
Correct answer: CMS Conditions of Participation requiring hospitals not to employ or contract with excluded individuals
CMS CoPs require hospitals to ensure they do not employ or contract with individuals excluded from participation in federal healthcare programs.
Question 4: During a credentialing audit, what is the purpose of a 'tracer methodology'?
- Following a specific patient's care record to evaluate provider competency documentation (Correct answer)
- Tracking the movement of credentials files between departments
- Auditing electronic health record access logs for providers
- Monitoring controlled substance prescribing patterns
Correct answer: Following a specific patient's care record to evaluate provider competency documentation
Tracer methodology follows a patient's care experience to evaluate whether practitioner credentialing and privileging supported safe, compliant care.
Question 5: An organization's policy requires state license verification every six months for all active providers. A credentialing specialist discovers the policy has not been followed for one department for two years. What is the appropriate escalation path?
- The specialist should independently verify all missing checks before reporting
- Report the compliance gap to the credentials committee and risk management immediately (Correct answer)
- Quietly correct the gap and document it without escalating
- File a complaint with the state licensing board
Correct answer: Report the compliance gap to the credentials committee and risk management immediately
A systemic compliance gap that exposes the organization to regulatory risk must be escalated to governance structures and risk management, not managed in isolation.
Question 6: Which of the following situations would most likely trigger an FPPE for a currently privileged physician?
- The physician requests an expansion of privileges to a new procedure (Correct answer)
- A pattern of late medical record completion
- The physician's DEA registration is due for renewal
- The physician transfers hospital employment to independent contractor status
Correct answer: The physician requests an expansion of privileges to a new procedure
Requests for new or expanded privileges that are outside the current scope require FPPE to evaluate competency in the new clinical area.
Question 7: A health plan conducts a monthly audit of its delegated credentialing entities. The audit finds that one delegated CVO has not been querying the NPDB for ongoing monitoring. What action is required?
- Immediately terminate the delegation agreement
- Issue a formal corrective action plan and set a timeline for compliance with a follow-up audit (Correct answer)
- Accept a written explanation and take no further action
- Transfer all affected provider files to the health plan for direct management
Correct answer: Issue a formal corrective action plan and set a timeline for compliance with a follow-up audit
Delegation oversight requirements under NCQA and URAC require that non-compliance by a delegated entity triggers a formal corrective action plan.
CPCS Ongoing Monitoring and Audits 4
A credentialing audit reveals that a practitioner's board certification lapsed 14 months ago and the provider did not self-report.
What policy violation does this most directly represent?