Compliance Monitoring & Auditing Flashcards

A plan delegates prior authorization functions to a specialty benefit manager (SBM). Under NCQA accreditation standards, which statement is TRUE?

Answer: The health plan retains oversight responsibility and must audit delegated functions

NCQA and CMS require that health plans retain oversight of all delegated functions and conduct ongoing audits of delegated entities.

Which of the following data elements is MOST valuable when benchmarking a plan's prior authorization denial rate against industry norms?

Answer: Service category, line of business, and region-adjusted denial rates

Meaningful benchmarking requires adjusting for service category, line of business, and regional variation to ensure like-to-like comparisons.

During a compliance audit, a reviewer discovers that a plan has been using clinical criteria that are two versions out of date for musculoskeletal PA requests. The IMMEDIATE compliance risk is:

Answer: Potential denial of medically necessary care based on outdated evidence

Outdated clinical criteria may not reflect current evidence, creating risk that medically necessary care is wrongly denied or inappropriately approved.

A compliance team wants to evaluate whether PA staff are correctly identifying requests that require physician-to-physician review. The BEST audit approach is:

Answer: Compare a sample of denied cases to the plan's physician review triggers and document any missed escalations

Comparing denied cases against established physician review triggers identifies cases that should have been escalated but were not, revealing gaps in escalation compliance.

Under the 2024 CMS Interoperability and Prior Authorization Final Rule, health plans must implement FHIR APIs for PA to promote:

Answer: Electronic submission and status tracking of PA requests to reduce administrative burden

The 2024 CMS rule requires FHIR-based PA APIs to enable electronic submission, real-time decision tracking, and reduced administrative burden for providers and plans.

A PACS compliance professional is reviewing audit scope and discovers that emergency services are included in the PA sample. What action should be taken?

Answer: Remove them from the PA sample, as federal regulations prohibit requiring PA for emergency services

Federal law prohibits health plans from requiring prior authorization for emergency services; auditing PA decisions for such services would reflect a fundamental compliance violation.

Which compliance control BEST prevents a PA reviewer from approving requests for services in which they have a personal financial interest?

Answer: Implementing a conflict of interest disclosure and recusal policy with automated routing controls

A formal conflict of interest policy combined with automated routing that prevents reviewers from processing conflicted cases is the most effective preventive control.