Compliance Monitoring & Auditing Flashcards

A health plan wants to audit whether its PA reviewers are applying clinical criteria consistently. Which audit methodology is MOST appropriate?

Answer: Inter-rater reliability study

An inter-rater reliability study compares decisions made by different reviewers on identical cases to assess consistency in criteria application.

When a compliance audit reveals that a prior authorization vendor is systematically denying requests without peer review, the FIRST step should be:

Answer: Conduct a root cause analysis and issue a cure notice to the vendor

A root cause analysis clarifies the scope of the problem, and a cure notice gives the vendor the contractual opportunity to correct the deficiency before escalation.

Which of the following is an example of a leading compliance indicator in prior authorization monitoring?

Answer: Percentage of PA requests missing required clinical documentation at intake

Incomplete documentation at intake is a leading indicator because it predicts future compliance failures before decisions are made.

A PACS auditor reviewing Medicaid managed care PA data must verify compliance with which federal rule that governs timely access standards?

Answer: 42 CFR Part 438

42 CFR Part 438 establishes federal requirements for Medicaid managed care plans, including timely access and coverage determination standards.

What does an overturn rate on appeal primarily indicate in a PA compliance audit?

Answer: Potential problems with initial PA denial decisions or criteria application

A high appeal overturn rate suggests that initial denials may lack adequate clinical justification or that criteria are being misapplied.

Which of the following sampling methods provides the MOST statistically valid representation of a prior authorization population for a compliance audit?

Answer: Simple random sampling with a defined confidence level and margin of error

Simple random sampling with defined confidence levels and margins of error produces statistically valid, defensible audit results.

A compliance team is preparing for a CMS Program Audit of its Medicare Advantage plan's coverage determinations. Which universe file is MOST critical to prepare accurately?

Answer: A complete, unduplicated list of all coverage determination and appeal cases in the audit period

CMS Program Audits require plans to submit accurate universe files of all coverage determinations and appeals, from which CMS selects its audit sample.