PACS Compliance Monitoring & Auditing 3

Question 1

A health plan wants to audit whether its PA reviewers are applying clinical criteria consistently. Which audit methodology is MOST appropriate?

Accepted Answer

Inter-rater reliability study

Answer

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:

Accepted Answer

Conduct a root cause analysis and issue a cure notice to the vendor

Answer

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?

Accepted Answer

Percentage of PA requests missing required clinical documentation at intake

Answer

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?

Accepted Answer

42 CFR Part 438

Answer

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?

Accepted Answer

Potential problems with initial PA denial decisions or criteria application

Answer

A high appeal overturn rate suggests that initial denials may lack adequate clinical justification or that criteria are being misapplied.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Compliance Monitoring & Auditing 3