Compliance Monitoring & Auditing Flashcards

A compliance audit finds that a plan's prior authorization letters do not include the specific clinical rationale for denial. This violates which regulatory requirement?

Answer: Notice requirements under 42 CFR Part 422 and Part 438

Federal regulations require that denial notices include the specific clinical rationale so members can meaningfully exercise their appeal rights.

Which scenario BEST illustrates a conflict of interest that a PA compliance program should monitor and control?

Answer: A medical director receiving productivity bonuses tied to denial rates

Bonuses tied to denial rates create a financial incentive to deny claims, constituting a prohibited conflict of interest that can bias medical necessity determinations.

Under the No Surprises Act's prior authorization transparency provisions, health plans must publicly report PA data including:

Answer: Percentage of PA requests approved, denied, and overturned on appeal by service category

The No Surprises Act requires plans to report aggregate PA statistics—approvals, denials, and appeal overturns—to support transparency and accountability.

A PACS professional conducts a retrospective review and discovers that 5% of approved PA requests resulted in services that were never rendered. This metric is MOST useful for monitoring:

Answer: Fraud, waste, and abuse within the provider network

Approved PAs for services never rendered may indicate fraudulent authorization requests or abuse patterns that warrant a fraud, waste, and abuse investigation.

What is the MINIMUM frequency that a comprehensive PA compliance monitoring program should conduct internal audits, according to best practice standards?

Answer: Annually, at minimum

Best practice compliance frameworks, including NCQA and URAC standards, recommend at minimum annual internal audits of prior authorization processes.

A compliance auditor is testing whether a plan's PA decisions align with its adopted clinical criteria. The auditor compares each decision to the InterQual or MCG criteria in use. This is an example of:

Answer: A clinical criteria adherence audit

Comparing PA decisions against the plan's adopted evidence-based clinical criteria tests whether reviewers are correctly applying those criteria.

Which element is MOST essential in a corrective action plan (CAP) developed in response to a PA compliance audit finding?

Answer: Root cause analysis, specific corrective steps, accountable owners, and measurable completion dates

An effective CAP must identify root causes, define specific corrective actions, assign ownership, and set measurable timelines for completion and validation.