PACS Compliance Monitoring & Auditing 3 — Questions and Answers
Question 1: A health plan wants to audit whether its PA reviewers are applying clinical criteria consistently. Which audit methodology is MOST appropriate?
- Financial reconciliation audit
- Inter-rater reliability study (Correct answer)
- Network adequacy review
- Credentialing file audit
Correct answer: Inter-rater reliability study
An inter-rater reliability study compares decisions made by different reviewers on identical cases to assess consistency in criteria application.
Question 2: When a compliance audit reveals that a prior authorization vendor is systematically denying requests without peer review, the FIRST step should be:
- Immediately terminate the vendor contract
- Notify affected members of the error
- Conduct a root cause analysis and issue a cure notice to the vendor (Correct answer)
- Report the vendor to the state insurance commissioner
Correct answer: Conduct a root cause analysis and issue a cure notice to the vendor
A root cause analysis clarifies the scope of the problem, and a cure notice gives the vendor the contractual opportunity to correct the deficiency before escalation.
Question 3: Which of the following is an example of a leading compliance indicator in prior authorization monitoring?
- Number of CMS sanctions issued last quarter
- Percentage of PA requests missing required clinical documentation at intake (Correct answer)
- Total denial rate for the prior year
- Number of appeals filed by members
Correct answer: Percentage of PA requests missing required clinical documentation at intake
Incomplete documentation at intake is a leading indicator because it predicts future compliance failures before decisions are made.
Question 4: A PACS auditor reviewing Medicaid managed care PA data must verify compliance with which federal rule that governs timely access standards?
- 42 CFR Part 438 (Correct answer)
- 45 CFR Part 164
- 42 CFR Part 2
- 29 CFR Part 2590
Correct answer: 42 CFR Part 438
42 CFR Part 438 establishes federal requirements for Medicaid managed care plans, including timely access and coverage determination standards.
Question 5: What does an overturn rate on appeal primarily indicate in a PA compliance audit?
- The frequency of fraudulent claims submitted by providers
- Potential problems with initial PA denial decisions or criteria application (Correct answer)
- The effectiveness of the plan's marketing department
- The accuracy of member eligibility verification
Correct answer: Potential problems with initial PA denial decisions or criteria application
A high appeal overturn rate suggests that initial denials may lack adequate clinical justification or that criteria are being misapplied.
Question 6: Which of the following sampling methods provides the MOST statistically valid representation of a prior authorization population for a compliance audit?
- Convenience sampling (auditing only the easiest-to-access cases)
- Judgmental sampling (hand-picking suspicious cases)
- Simple random sampling with a defined confidence level and margin of error (Correct answer)
- Auditing only cases flagged by providers
Correct answer: Simple random sampling with a defined confidence level and margin of error
Simple random sampling with defined confidence levels and margins of error produces statistically valid, defensible audit results.
Question 7: A compliance team is preparing for a CMS Program Audit of its Medicare Advantage plan's coverage determinations. Which universe file is MOST critical to prepare accurately?
- A list of all network providers and their specialties
- A complete, unduplicated list of all coverage determination and appeal cases in the audit period (Correct answer)
- All member grievances related to billing errors
- The plan's formulary exclusion list
Correct answer: A complete, unduplicated list of all coverage determination and appeal cases in the audit period
CMS Program Audits require plans to submit accurate universe files of all coverage determinations and appeals, from which CMS selects its audit sample.
PACS Compliance Monitoring & Auditing 3
A health plan wants to audit whether its PA reviewers are applying clinical criteria consistently.
Which audit methodology is MOST appropriate?