CPCS CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers 2 — Questions and Answers
Question 1: How frequently must organizations participating in the Medicare and Medicaid programs check practitioners against the OIG List of Excluded Individuals/Entities (LEIE)?
- Annually only
- At initial credentialing only
- At least monthly, per OIG guidance (Correct answer)
- Only when a complaint is received
Correct answer: At least monthly, per OIG guidance
The OIG recommends that healthcare organizations check the LEIE at least monthly to ensure no currently participating practitioners or employees are excluded from federal healthcare programs.
The OIG strongly recommends that organizations check the LEIE monthly (not just at initial credentialing or annual review) because exclusions can occur at any time. Employing or contracting with an excluded individual can result in significant civil monetary penalties under the Social Security Act, regardless of whether the organization knew about the exclusion. The OIG LEIE is freely accessible online, making monthly automated checks feasible. Organizations should also check SAM.gov (for federal contracts) and state Medicaid exclusion lists, which may differ from the federal LEIE.
Question 2: During a credentialing audit, a surveyor finds that OPPE reports have not been provided to practitioners at any point during the past 18 months. Under TJC standards, this would be considered which type of deficiency?
- A minor documentation gap
- A Requirement for Improvement (RFI) (Correct answer)
- An Immediate Threat to Life (ITL) finding
- A Sentinel Event finding
Correct answer: A Requirement for Improvement (RFI)
Failure to conduct OPPE at the required interval (at least every 6 months) would be cited as a Requirement for Improvement under TJC standards, requiring submission of an Evidence of Standards Compliance.
Under TJC's scoring system, findings are categorized as: Immediate Threat to Life (ITL, most severe), Requirement for Improvement (RFI, requires corrective action), or Satisfactory. Failure to conduct OPPE reviews at intervals not exceeding 6 months is a violation of TJC MS.08.01.03 and would be cited as an RFI. This requires the organization to submit an Evidence of Standards Compliance (ESC) within a defined timeframe demonstrating the deficiency has been corrected.
Question 3: An organization is implementing continuous monitoring for its practitioner network. Which database should be checked to identify practitioners who have had DEA registration revoked or surrendered?
- The NPDB only
- The DEA Diversion Control Division website (Correct answer)
- The state pharmacy board website
- CAQH ProView
Correct answer: The DEA Diversion Control Division website
DEA registration actions (revocation, suspension, surrender) can be verified through the DEA Diversion Control Division website or by contacting the DEA directly, in addition to NPDB which also receives DEA adverse action reports.
DEA registration status can be verified through: (1) the DEA Diversion Control Division website (allows verification of current DEA registration status), (2) the NPDB (which receives reports of DEA certificate revocations and surrenders that meet reporting criteria), and (3) direct inquiry to the DEA. As part of continuous monitoring, organizations should verify DEA registration status for all practitioners authorized to prescribe controlled substances. CAQH ProView contains self-reported data and is not primary source for DEA status.
Question 4: What is the primary purpose of conducting a 'focused audit' of credentialing files?
- To replace the need for ongoing primary source verification
- To identify specific compliance gaps or areas needing improvement in the credentialing process (Correct answer)
- To satisfy annual HIPAA audit requirements
- To determine practitioner compensation adjustments
Correct answer: To identify specific compliance gaps or areas needing improvement in the credentialing process
Focused audits target specific elements or processes in the credentialing program to identify compliance gaps, assess adherence to policies, and identify areas for process improvement.
Focused audits are quality improvement tools that examine specific aspects of the credentialing program, such as: completeness of files in a particular department, timeliness of processing initial applications, accuracy of expirable tracking, or compliance with a specific accreditation standard. They differ from comprehensive audits (which review all elements) in that they have a targeted scope. Findings from focused audits are used to drive process improvements, update policies and procedures, and provide targeted training to credentialing staff.
Question 5: A credentialing manager is developing a quality dashboard for the credentialing program. Which of the following metrics would best measure the efficiency of the initial credentialing process?
- Number of NPDB reports received per month
- Average number of days from completed application receipt to committee approval (Correct answer)
- Number of practitioners recredentialed per year
- Percentage of practitioners with malpractice claims
Correct answer: Average number of days from completed application receipt to committee approval
Average processing time from completed application to committee approval directly measures the efficiency of the initial credentialing workflow and can be benchmarked against industry standards and accreditation requirements.
The average time from receipt of a completed application to committee approval (often called 'cycle time' or 'turnaround time') is the primary efficiency metric for initial credentialing. Industry benchmarks and accreditation standards (URAC requires completion within 120 days) make this a meaningful, comparable metric. Other important dashboard metrics might include: percentage of files complete at 30/60/90 days, number of files pending beyond policy timeframes, and percentage of applications requiring committee review vs. clean applications. These metrics support continuous quality improvement.
Question 6: An organization's recredentialing audit reveals that 8% of practitioners have not been sent recredentialing letters within the policy-required timeframe. This finding should be addressed through which quality improvement mechanism?
- Immediate suspension of all affected practitioners
- A root cause analysis to identify why the timing requirement is not being met, followed by process correction (Correct answer)
- Reporting each practitioner to the NPDB for non-compliance
- Requesting an extension from the accreditation body
Correct answer: A root cause analysis to identify why the timing requirement is not being met, followed by process correction
A systematic process failure (8% non-compliance with policy) should be addressed through root cause analysis to identify why the process is failing, followed by targeted process improvements.
When an audit reveals a systematic process problem (rather than an isolated error), the appropriate quality improvement response is: (1) conduct a root cause analysis to identify contributing factors (understaffing, workflow gaps, system failures, etc.), (2) develop and implement targeted corrective actions, (3) re-audit to verify that the corrective actions are effective, and (4) document the entire process for accreditation purposes. The practitioners are not at fault for an organizational process failure, so practitioner-level sanctions would be inappropriate. This is a process management issue.
CPCS CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers 2
How frequently must organizations participating in the Medicare and Medicaid programs check practitioners against the OIG List of Excluded Individuals/Entities (LEIE)?