Risk Assessment & Management Flashcards

A payer's prior authorization policy requires additional clinical review when a requested service exceeds a cost threshold. What is this type of risk control called?

Answer: Cost-based clinical threshold trigger

Cost-based clinical threshold triggers are risk controls that initiate enhanced review when a service cost exceeds a defined limit.

Which federal regulation most directly governs the risk that a Medicare Advantage plan faces when denying prior authorization requests?

Answer: 42 CFR Part 422

42 CFR Part 422 establishes CMS rules for Medicare Advantage plans, including standards for prior authorization denials and appeals.

A health plan identifies that a provider is submitting prior authorization requests for procedures with a high rate of post-service adverse outcomes. What risk management step is most appropriate?

Answer: Initiate a focused clinical review and provider education program

A focused clinical review and provider education addresses the quality risk while maintaining the care relationship and due process.

What does 'false negative' risk mean in the context of prior authorization?

Answer: Denying a medically necessary service that should have been approved

A false negative in PA means the system incorrectly denied a service that was clinically appropriate, creating access-to-care and liability risk.

An insurer uses predictive modeling to flag high-cost members before they request services. This is an example of which risk management approach?

Answer: Proactive population health risk stratification

Proactive population health risk stratification identifies high-risk members in advance so interventions can be deployed before costly events occur.

When assessing authorization risk for a new specialty drug, which factor carries the MOST clinical weight?

Answer: Evidence-based clinical guidelines and FDA-approved indications

Evidence-based clinical guidelines and FDA-approved indications are the primary clinical benchmarks for evaluating specialty drug authorization requests.

A prior authorization specialist notices that denial letters for behavioral health services are less detailed than those for medical services. What compliance risk does this create?

Answer: Mental Health Parity and Addiction Equity Act (MHPAEA) violations

MHPAEA requires that denial criteria and processes for behavioral health be no more restrictive than for comparable medical/surgical benefits.