PACS PACS Clinical Review & Utilization Management 1 — Questions and Answers
Question 1: What is the primary purpose of utilization management (UM) in the prior authorization process?
- To increase the profitability of insurance companies
- To ensure that healthcare services are medically necessary, appropriate, and cost-effective (Correct answer)
- To reduce the number of physicians allowed to prescribe specialty drugs
- To standardize patient co-payments across all health plans
Correct answer: To ensure that healthcare services are medically necessary, appropriate, and cost-effective
Utilization management ensures that healthcare services meet criteria for medical necessity, appropriateness, and cost-effectiveness before authorization is granted.
Question 2: Which organization is widely known for developing evidence-based clinical criteria used in utilization management and prior authorization decisions?
- The American Medical Association (AMA)
- InterQual (Change Healthcare) and Milliman Care Guidelines (Correct answer)
- The Joint Commission (TJC)
- The National Committee for Quality Assurance (NCQA)
Correct answer: InterQual (Change Healthcare) and Milliman Care Guidelines
InterQual (Change Healthcare) and Milliman Care Guidelines are the most widely used evidence-based clinical criteria sets in utilization management and prior authorization decisions.
Question 3: What is 'step therapy' in the context of prior authorization for medications?
- A protocol requiring patients to try lower-cost or first-line treatments before a preferred or specialty drug is approved (Correct answer)
- A gradual dose escalation protocol for high-risk medications
- A process for transitioning patients between insurance plans
- A therapy that requires multiple physician approvals before initiation
Correct answer: A protocol requiring patients to try lower-cost or first-line treatments before a preferred or specialty drug is approved
Step therapy, or 'fail-first' protocols, requires patients to try specified first-line or lower-cost treatments before a health plan will authorize coverage for a more expensive alternative.
Question 4: In utilization management, what is a 'concurrent review'?
- A review conducted before a service or admission begins
- A review of a patient's care while they are currently receiving inpatient services (Correct answer)
- A retrospective review of services after discharge
- A review performed simultaneously by two independent clinicians
Correct answer: A review of a patient's care while they are currently receiving inpatient services
Concurrent review evaluates the medical necessity of continued inpatient care while the patient is currently admitted and receiving services.
Question 5: Which federal law requires that mental health and substance use disorder benefits in employer-sponsored plans be provided at parity with medical/surgical benefits?
- The Americans with Disabilities Act (ADA)
- The Mental Health Parity and Addiction Equity Act (MHPAEA) (Correct answer)
- HIPAA
- The Emergency Medical Treatment and Labor Act (EMTALA)
Correct answer: The Mental Health Parity and Addiction Equity Act (MHPAEA)
The Mental Health Parity and Addiction Equity Act (MHPAEA) requires that mental health and substance use disorder benefits be provided at parity with medical/surgical benefits.
Question 6: What is a 'formulary exception' request in the context of prescription drug prior authorization?
- A request to add a new drug to the insurance plan's formulary permanently
- A request for coverage of a non-formulary drug when a formulary alternative is inappropriate for the patient (Correct answer)
- A request to waive the co-payment for a formulary drug
- A request to use a generic drug in place of a brand-name drug
Correct answer: A request for coverage of a non-formulary drug when a formulary alternative is inappropriate for the patient
A formulary exception requests coverage for a non-formulary drug when the available formulary alternatives are clinically inappropriate or contraindicated for that specific patient.
PACS PACS Clinical Review & Utilization Management 1
What is the primary purpose of utilization management (UM) in the prior authorization process?