Risk Assessment & Management Flashcards

A member's physician requests authorization for a high-cost imaging study but the plan's criteria require a step-therapy trial of a lower-cost alternative first. What type of risk management tool is step therapy?

Answer: Clinical appropriateness and cost-management protocol

Step therapy is a clinical appropriateness protocol that manages both quality and cost risk by requiring less intensive or costly treatments before higher-cost options.

What is the primary legal risk to a health plan if its prior authorization criteria are not based on current clinical evidence?

Answer: Exposure to bad faith denial claims and regulatory sanctions

Using outdated or non-evidence-based criteria exposes a plan to bad faith denial claims and regulatory sanctions for failing to apply sound clinical standards.

A prior authorization program shows a 40% overturn rate on appeal. What does this data signal about risk?

Answer: Initial PA decision criteria may be overly restrictive or improperly applied

A high overturn rate on appeal suggests initial denial criteria are either too strict or inconsistently applied, creating clinical and legal risk.

A hospital submits a prior authorization request with incomplete clinical documentation. Under risk management best practice, what should occur?

Answer: The reviewer should request the missing information and pause the decision clock

Best practice is to request missing documentation and pause the decision clock, ensuring a complete clinical review without penalizing the provider or member prematurely.

Which scenario most increases the risk of a prior authorization process being found discriminatory?

Answer: Requiring additional documentation for a specific diagnosis that disproportionately affects a protected class

Requiring additional documentation for a diagnosis that disproportionately affects a protected class can constitute disparate impact discrimination under civil rights laws.

A PACS professional is asked to identify leading indicators of prior authorization program risk. Which of the following is a LEADING indicator?

Answer: Trend in first-pass approval rate over the last 30 days

A trend in first-pass approval rate is a leading indicator because it signals emerging patterns before they generate complaints, lawsuits, or regulatory action.

When a PACS specialist identifies a pattern of inappropriate authorizations tied to a specific diagnosis code, what risk management action is most appropriate?

Answer: Conduct a focused retrospective audit and escalate findings to the medical director

A focused retrospective audit followed by escalation to the medical director is the appropriate process to investigate and address a pattern of potentially inappropriate authorizations.