Risk Assessment & Management Flashcards

A state passes a law requiring health plans to disclose their prior authorization criteria publicly. What risk does non-compliance create?

Answer: State regulatory sanctions and potential loss of licensure

Failing to comply with state disclosure laws for PA criteria can result in regulatory sanctions, fines, and in severe cases, loss of the plan's operating license.

A care manager notices that a member with multiple chronic conditions has had three prior authorizations denied for the same service in one year. What risk does this pattern signal?

Answer: The plan may face a bad faith claim and the member may need case management intervention

Repeated denials for the same member may signal that criteria are being misapplied and could expose the plan to bad faith litigation while leaving a vulnerable member without needed care.

Which element of a prior authorization denial letter is most critical for managing legal risk?

Answer: The specific clinical criteria used and the clinical rationale for the denial

Specific clinical criteria and rationale are legally required in denial letters and are the primary defense in any appeal or bad faith litigation.

A prior authorization program's risk assessment reveals a high volume of requests from a single provider for a procedure with low evidence of efficacy. What is the BEST immediate risk mitigation step?

Answer: Place the procedure under enhanced clinical review criteria and notify the medical director

Enhanced clinical review criteria for a low-evidence procedure ensures clinical rigor is applied while the medical director determines whether further action is warranted.

Under the No Surprises Act, which prior authorization scenario carries added federal compliance risk?

Answer: Denying emergency services based on a prior authorization requirement

The No Surprises Act prohibits plans from applying prior authorization requirements to emergency services, making such denials a federal compliance violation.

A risk manager wants to reduce the chance that PA reviewers make inconsistent decisions on similar cases. What is the most effective tool?

Answer: Standardized clinical criteria and regular inter-rater reliability audits

Standardized clinical criteria paired with inter-rater reliability audits directly measure and address inconsistency in reviewer decisions.

A PACS professional is designing a risk scorecard for the PA program. Which combination of metrics provides the most balanced view of program risk?

Answer: Turnaround time compliance, overturn rate on appeal, and denial rate by service category

Turnaround time compliance, overturn rate on appeal, and denial rate by service category together capture operational, clinical, and legal risk dimensions of a PA program.