Compliance Monitoring & Auditing Flashcards

A payer's compliance team discovers that 12% of prior authorization denials lacked adequate clinical documentation in the file. What is the MOST appropriate immediate action?

Answer: Conduct a focused corrective action review and implement documentation standards

A focused corrective action review paired with updated documentation standards directly addresses the root cause of the compliance gap.

Which federal regulation requires Medicare Advantage plans to maintain records sufficient to support prior authorization decisions for a minimum of 10 years?

Answer: 42 CFR Part 422

42 CFR Part 422 governs Medicare Advantage plan requirements, including record retention standards for coverage determinations.

During a compliance audit, a reviewer finds that a plan routinely approved PAs for a high-cost drug without verifying step therapy requirements. This is BEST categorized as:

Answer: A systemic compliance gap requiring corrective action

Routine failure to enforce step therapy requirements reflects a systemic process gap, not necessarily intentional fraud or abuse.

What is the primary purpose of a compliance monitoring dashboard in a prior authorization department?

Answer: To provide real-time visibility into key compliance metrics and flag outliers

Compliance dashboards enable proactive identification of trends and outliers before they escalate into regulatory violations.

A PACS professional is reviewing a sample of PA decisions and finds that 8% were decided after the regulatory timeframe. Which metric is being measured?

Answer: Turnaround time compliance rate

Measuring the percentage of decisions made within required timeframes is the turnaround time compliance rate, a key regulatory metric.

Under CMS rules, what must a Medicare Advantage plan do if an audit reveals a pattern of untimely prior authorization decisions?

Answer: File a corrective action plan (CAP) with CMS

CMS requires Medicare Advantage organizations to submit corrective action plans when audits identify patterns of non-compliance with coverage determination timelines.

Which of the following BEST describes the role of a compliance officer in a prior authorization audit process?

Answer: Overseeing audit design, findings review, and corrective action implementation

The compliance officer's role in audits centers on governance: designing audits, interpreting findings, and ensuring corrective actions are implemented.