CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers

Question 1

A credentialing specialist is notified by the state medical board that a practitioner's license has been suspended pending investigation.
The practitioner is currently credentialed and privileged.
What is the MOST appropriate immediate action for the specialist to take?

Accepted Answer

Initiate the summary suspension process according to medical staff bylaws.

Answer

Continue to monitor the situation and report it at the next reappointment cycle.

Answer

Send a certified letter to the practitioner requesting an explanation.

Answer

Wait for the practitioner to self-report the suspension.

Question 2

What is the primary purpose of conducting routine internal audits of credentialing files?

Accepted Answer

To identify opportunities for process improvement and ensure ongoing compliance with accrediting body standards.

Answer

To discipline credentialing staff for minor errors found in the files.

Answer

To prepare a summary report for the hospital's marketing department.

Answer

To eliminate the need for external audits by health plans or accreditors.

Question 3

Which of the following is an essential component of an effective ongoing monitoring program for a hospital, as specifically required by The Joint Commission (TJC)?

Accepted Answer

Implementing an Ongoing Professional Practice Evaluation (OPPE) process.

Answer

Sending a monthly newsletter to all medical staff members.

Answer

Reviewing patient satisfaction scores once per reappointment cycle.

Answer

Requiring all practitioners to attend the annual staff holiday party.

Question 4

During a delegation audit, a health plan auditor reviews a provider file at a medical group. The auditor notes the credentialing committee approved the provider on May 10th. Which of the following discoveries in the file would constitute a significant finding of non-compliance with NCQA standards?

Accepted Answer

The query to the National Practitioner Data Bank (NPDB) is dated May 15th of the same year.

Answer

The primary source verification for the medical license is a letter directly from the state board.

Answer

The provider's application attestation was signed on April 1st of the same year.

Answer

The file includes a copy of the provider's current, valid DEA certificate.

Question 5

Continuous monitoring involves regularly checking specific databases between credentialing cycles to identify any new adverse actions. Which two databases are most commonly queried for this purpose to check for federal program exclusions?

Accepted Answer

The Office of Inspector General (OIG) List of Excluded Individuals/Entities and the System for Award Management (SAM).

Answer

The National Practitioner Data Bank (NPDB) and the practitioner's medical school alumni database.

Answer

The Drug Enforcement Administration (DEA) and the American Board of Medical Specialties (ABMS).

Answer

The AMA Physician Masterfile and the Federation of State Medical Boards (FSMB).

Question 6

A Corrective Action Plan (CAP) is often required following an audit that reveals deficiencies. Which of the following is the MOST critical element of an effective CAP?

Accepted Answer

A detailed description of the root cause of the non-compliance and the specific steps to be taken to prevent recurrence.

Answer

A request for a budget increase to hire additional credentialing staff.

Answer

A statement assigning blame to a specific employee for the deficiency.

Answer

A simple acknowledgment that the deficiency was noted by the auditor.