Continuous Improvement & Updates Flashcards

A prior authorization (PA) team notices that 30% of oncology requests are returned for additional clinical information. Which continuous improvement action best addresses this systemic issue?

Answer: Develop a disease-specific PA checklist outlining required clinical documentation upfront

A disease-specific checklist ensures submitters include all required clinical information the first time, reducing returns and rework.

When evaluating the effectiveness of a recently implemented PA workflow change, which metric is MOST directly tied to patient access to care?

Answer: Time from PA submission to final determination

Turnaround time from submission to determination directly measures how quickly patients can access the services they need.

A health plan updates its PA clinical criteria for a drug class mid-year. What is the FIRST step a PA specialist should take upon learning of this update?

Answer: Alert the compliance team and update internal reference tools to reflect new criteria

Promptly updating internal reference tools and notifying compliance ensures decisions are based on current criteria and reduces liability.

Which of the following best describes a 'Plan-Do-Study-Act' (PDSA) cycle in the context of PA operations?

Answer: A structured iterative method for testing and implementing process improvements

PDSA is a continuous quality improvement model that tests changes on a small scale, studies results, and refines before full implementation.

A PA department's denial rate increases following the adoption of a new electronic submission platform. What continuous improvement step should be taken first?

Answer: Perform a root cause analysis to determine if the platform is causing submission errors

Root cause analysis identifies whether the platform is introducing errors before deciding on a corrective course of action.

Which regulatory framework requires health plans to update PA standards and notify providers of changes in a timely manner under managed care contracts?

Answer: NCQA accreditation standards for utilization management

NCQA utilization management standards require health plans to communicate PA criteria updates to providers and maintain timely determination processes.

A PA team implements monthly audits of approved and denied cases. What is the PRIMARY purpose of including approved cases in the audit?

Answer: To identify cases where approval may have been granted in error, supporting staff education

Auditing approvals helps identify inappropriate approvals, ensuring consistent and compliant decision-making across all case types.