Ongoing Monitoring and Audits Flashcards
7 cards from real CPCS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Ongoing Monitoring and Audits flashcards as text
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?
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.
Which of the following metrics would be LEAST useful as an OPPE indicator for an emergency medicine physician?
Answer: Surgical site infection rates
Surgical site infection rates are not applicable to emergency medicine physicians who do not perform surgery in that role.
What is the primary regulatory driver requiring Medicare-participating hospitals to conduct ongoing monitoring of provider exclusion status?
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.
During a credentialing audit, what is the purpose of a 'tracer methodology'?
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.
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?
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.
Which of the following situations would most likely trigger an FPPE for a currently privileged physician?
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.
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?
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.