CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers Flashcards
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Read the first 6 CPCS - Certified Provider Credentialing Specialist Ongoing Monitoring and Audits Questions and Answers flashcards as text
What is the recommended practice for handling a practitioner who has been re-enrolled in Medicare after a period of exclusion?
Answer: The credentialing committee should review the circumstances of the exclusion and re-enrollment before credentialing or recredentialing
A history of Medicare/Medicaid exclusion should be reviewed by the credentials committee, even after re-enrollment, to assess the circumstances and determine appropriate credentialing action.
Which of the following best describes the purpose of conducting a 'random file audit' as part of an ongoing credentialing quality program?
Answer: To test whether the credentialing process produces consistently compliant files across the practitioner population
Random file audits test the credentialing process itself by checking whether randomly selected files meet all compliance requirements, identifying systematic gaps without focusing only on problem cases.
A hospital discovers that a practitioner has been practicing with an expired medical license for 3 months without the medical staff office's knowledge. What immediate steps should be taken?
Answer: Immediately suspend clinical privileges, notify hospital administration and legal counsel, investigate how the gap occurred, and determine reporting obligations
Practicing with an expired license is a serious legal and patient safety issue requiring immediate privilege suspension, notification of administration and legal counsel, investigation of the process failure, and evaluation of reporting and disclosure obligations.
Under NCQA standards, which of the following monitoring activities is required between the three-year credentialing cycles?
Answer: Checking the OIG LEIE and SAM.gov exclusion lists
NCQA requires health plans to monitor for exclusions from federal healthcare programs (OIG LEIE and SAM.gov) for network practitioners as part of ongoing monitoring between credentialing cycles.
An organization is reviewing its credentialing audit schedule. Under NCQA standards, how frequently must delegated credentialing activities be audited?
Answer: At least annually
NCQA requires that organizations with delegated credentialing arrangements conduct ongoing oversight, which includes at least annual auditing of the delegate's credentialing activities.
Which of the following is the best description of the 'sanction screening' component of ongoing monitoring?
Answer: Systematically checking practitioners against federal and state exclusion lists, license databases, and adverse action databases on a scheduled basis
Sanction screening involves systematically and regularly checking practitioners against exclusion lists (OIG LEIE, SAM.gov), state Medicaid exclusion lists, and license databases to identify adverse actions as they occur.