CPCS Ongoing Monitoring and Audits 5 — Questions and Answers
Question 1: Under NCQA credentialing standards, how frequently must a health plan re-credential its network providers?
- Every year
- Every two years
- Every three years (Correct answer)
- Every five years
Correct answer: Every three years
NCQA standards require health plans to recredential network practitioners at least every three years.
Question 2: 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?
- Ignore the change until the next scheduled recredentialing
- Notify the provider and require evidence of coverage meeting the minimum threshold within a defined timeframe (Correct answer)
- Immediately revoke the provider's clinical privileges without notice
- Report the carrier to the state insurance commissioner
Correct 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.
Question 3: Which of the following best describes the concept of 'continuous monitoring' in modern credentialing programs?
- Manually checking each provider's credentials every 30 days
- Using automated, real-time or near-real-time alerts from databases to flag credential changes as they occur (Correct answer)
- Conducting full recredentialing every six months for high-risk providers
- Requiring providers to log in to a portal and confirm credentials are current monthly
Correct 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.
Question 4: 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?
- The principle of respondeat superior
- The corporate negligence doctrine requiring hospitals to monitor and act on known competency concerns (Correct answer)
- EMTALA transfer obligations
- The learned intermediary doctrine
Correct 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.
Question 5: 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?
- Revoke the DEA registration from the provider's file immediately
- Flag the inconsistency for medical staff leadership review to determine if the DEA registration is clinically appropriate for the granted privileges (Correct answer)
- Report the provider to the DEA for investigation
- Take no action as the DEA registration may be grandfathered
Correct 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.
Question 6: Which type of credentialing audit assesses whether the organization's own credentialing policies and procedures conform to accreditation standards?
- File completeness audit
- Regulatory compliance audit
- Standards compliance audit (Correct answer)
- Delegation oversight audit
Correct 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.
Question 7: A credentialing program implements a 90-60-30 day expiration tracking system. What is the primary benefit of the 90-day advance alert?
- It allows the organization to bill the provider for administrative costs
- It provides sufficient lead time to resolve complex renewals before a credential lapses, preventing privilege suspension (Correct answer)
- It triggers an automatic FPPE review of the provider
- It satisfies the CMS primary source verification requirement
Correct 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.
CPCS Ongoing Monitoring and Audits 5
Under NCQA credentialing standards, how frequently must a health plan re-credential its network providers?