Risk Assessment & Management Flashcards

A specialist requests prior authorization for an off-label use of a biologic agent. What is the primary risk the PA reviewer must evaluate?

Answer: Clinical evidence supporting safety and efficacy for the off-label indication

Off-label requests require rigorous evaluation of peer-reviewed evidence and clinical guidelines to determine if the use is medically supported.

Which metric best measures the downstream risk of a prior authorization program that is too restrictive?

Answer: Rate of emergency department visits following PA denials

An increase in ED visits following PA denials suggests members are forgoing needed care and accessing emergency services instead, indicating the program is too restrictive.

Under the ACA's internal appeals requirements, what is the maximum time a health plan has to issue an urgent care prior authorization decision?

Answer: 72 hours

Federal regulations require that urgent care prior authorization decisions be made within 72 hours of receiving the request.

A PA coordinator discovers that a physician's office has been submitting duplicate authorization requests for the same service to increase the chance of approval. What category of risk does this represent?

Answer: Administrative fraud and abuse risk

Submitting duplicate requests to game the approval system is an administrative fraud and abuse risk that can trigger compliance investigations.

A risk manager is evaluating the plan's PA program after receiving multiple member complaints about delays. What is the first data point to review?

Answer: Average days to decision compared to regulatory turnaround standards

Average days to decision compared to regulatory standards directly identifies whether the plan is meeting legally required turnaround times that may be driving complaints.

When a health plan delegates prior authorization functions to a vendor, what risk transfer mechanism must be in place?

Answer: A delegation agreement with audit rights, performance standards, and liability provisions

A formal delegation agreement with audit rights, performance standards, and liability provisions is required to ensure regulatory accountability and operational oversight.

Which scenario represents a 'false positive' risk in prior authorization?

Answer: Approving a service that is later found to be medically unnecessary or fraudulent

A false positive in PA means approving a service that was not medically necessary, which creates financial waste and potential fraud liability.