PACS Compliance Monitoring & Auditing 2

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?

Accepted Answer

Conduct a focused corrective action review and implement documentation standards

Answer

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?

Accepted Answer

42 CFR Part 422

Answer

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:

Accepted Answer

A systemic compliance gap requiring corrective action

Answer

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?

Accepted Answer

To provide real-time visibility into key compliance metrics and flag outliers

Answer

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?

Accepted Answer

Turnaround time compliance rate

Answer

Measuring the percentage of decisions made within required timeframes is the turnaround time compliance rate, a key regulatory metric.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Compliance Monitoring & Auditing 2