PACS Compliance Monitoring & Auditing 2 — Questions and Answers
Question 1: A payer's compliance team discovers that 12% of prior authorization denials lacked adequate clinical documentation in the file. What is the MOST appropriate immediate action?
- Terminate the staff responsible for the denials
- Conduct a focused corrective action review and implement documentation standards (Correct answer)
- Report the finding to CMS within 24 hours
- Suspend all PA processing until the issue is resolved
Correct answer: Conduct a focused corrective action review and implement documentation standards
A focused corrective action review paired with updated documentation standards directly addresses the root cause of the compliance gap.
Question 2: Which federal regulation requires Medicare Advantage plans to maintain records sufficient to support prior authorization decisions for a minimum of 10 years?
- HIPAA Privacy Rule
- 42 CFR Part 422 (Correct answer)
- 42 CFR Part 2
- The False Claims Act
Correct answer: 42 CFR Part 422
42 CFR Part 422 governs Medicare Advantage plan requirements, including record retention standards for coverage determinations.
Question 3: During a compliance audit, a reviewer finds that a plan routinely approved PAs for a high-cost drug without verifying step therapy requirements. This is BEST categorized as:
- Fraud
- A systemic compliance gap requiring corrective action (Correct answer)
- Abuse
- An isolated billing error
Correct answer: A systemic compliance gap requiring corrective action
Routine failure to enforce step therapy requirements reflects a systemic process gap, not necessarily intentional fraud or abuse.
Question 4: What is the primary purpose of a compliance monitoring dashboard in a prior authorization department?
- To track employee attendance and productivity
- To provide real-time visibility into key compliance metrics and flag outliers (Correct answer)
- To generate billing reports for the finance department
- To document member grievances
Correct answer: To provide real-time visibility into key compliance metrics and flag outliers
Compliance dashboards enable proactive identification of trends and outliers before they escalate into regulatory violations.
Question 5: A PACS professional is reviewing a sample of PA decisions and finds that 8% were decided after the regulatory timeframe. Which metric is being measured?
- Denial rate
- Turnaround time compliance rate (Correct answer)
- Appeal overturn rate
- Administrative error rate
Correct answer: Turnaround time compliance rate
Measuring the percentage of decisions made within required timeframes is the turnaround time compliance rate, a key regulatory metric.
Question 6: Under CMS rules, what must a Medicare Advantage plan do if an audit reveals a pattern of untimely prior authorization decisions?
- File a corrective action plan (CAP) with CMS (Correct answer)
- Immediately suspend all non-urgent PA requests
- Transfer affected members to fee-for-service Medicare
- Only address the issue during the next annual audit cycle
Correct answer: File a corrective action plan (CAP) with CMS
CMS requires Medicare Advantage organizations to submit corrective action plans when audits identify patterns of non-compliance with coverage determination timelines.
Question 7: Which of the following BEST describes the role of a compliance officer in a prior authorization audit process?
- Approving individual PA requests when clinicians are unavailable
- Overseeing audit design, findings review, and corrective action implementation (Correct answer)
- Setting clinical criteria for medical necessity determinations
- Negotiating provider contracts on behalf of the plan
Correct answer: Overseeing audit design, findings review, and corrective action implementation
The compliance officer's role in audits centers on governance: designing audits, interpreting findings, and ensuring corrective actions are implemented.
PACS Compliance Monitoring & Auditing 2
A payer's compliance team discovers that 12% of prior authorization denials lacked adequate clinical documentation in the file.
What is the MOST appropriate immediate action?