PACS Continuous Improvement & Updates 2 — Questions and Answers
Question 1: A prior authorization (PA) team notices that 30% of oncology requests are returned for additional clinical information. Which continuous improvement action best addresses this systemic issue?
- Increase staff overtime to process returned requests faster
- Develop a disease-specific PA checklist outlining required clinical documentation upfront (Correct answer)
- Assign a dedicated reviewer to handle only oncology denials
- Stop accepting oncology PA requests until the issue resolves
Correct answer: Develop a disease-specific PA checklist outlining required clinical documentation upfront
A disease-specific checklist ensures submitters include all required clinical information the first time, reducing returns and rework.
Question 2: When evaluating the effectiveness of a recently implemented PA workflow change, which metric is MOST directly tied to patient access to care?
- Average staff login time per day
- Number of PA requests submitted per week
- Time from PA submission to final determination (Correct answer)
- Cost per PA request processed
Correct answer: Time from PA submission to final determination
Turnaround time from submission to determination directly measures how quickly patients can access the services they need.
Question 3: A health plan updates its PA clinical criteria for a drug class mid-year. What is the FIRST step a PA specialist should take upon learning of this update?
- Continue applying old criteria until the annual renewal period
- Alert the compliance team and update internal reference tools to reflect new criteria (Correct answer)
- Deny all pending requests in that drug class pending review
- Notify patients directly about the criteria change
Correct answer: Alert the compliance team and update internal reference tools to reflect new criteria
Promptly updating internal reference tools and notifying compliance ensures decisions are based on current criteria and reduces liability.
Question 4: Which of the following best describes a 'Plan-Do-Study-Act' (PDSA) cycle in the context of PA operations?
- A legal framework for appealing PA denials at the federal level
- A reimbursement model used by Medicare Advantage plans
- A structured iterative method for testing and implementing process improvements (Correct answer)
- A payer audit protocol for reviewing PA accuracy
Correct answer: A structured iterative method for testing and implementing process improvements
PDSA is a continuous quality improvement model that tests changes on a small scale, studies results, and refines before full implementation.
Question 5: A PA department's denial rate increases following the adoption of a new electronic submission platform. What continuous improvement step should be taken first?
- Revert immediately to paper-based submissions
- Perform a root cause analysis to determine if the platform is causing submission errors (Correct answer)
- Hire additional staff to handle the increased denial volume
- Escalate all denials to peer-to-peer review automatically
Correct answer: Perform a root cause analysis to determine if the platform is causing submission errors
Root cause analysis identifies whether the platform is introducing errors before deciding on a corrective course of action.
Question 6: Which regulatory framework requires health plans to update PA standards and notify providers of changes in a timely manner under managed care contracts?
- OSHA Hazard Communication Standard
- NCQA accreditation standards for utilization management (Correct answer)
- IRS Section 501(c)(3) tax-exempt rules
- HIPAA Security Rule for electronic PHI
Correct answer: NCQA accreditation standards for utilization management
NCQA utilization management standards require health plans to communicate PA criteria updates to providers and maintain timely determination processes.
Question 7: A PA team implements monthly audits of approved and denied cases. What is the PRIMARY purpose of including approved cases in the audit?
- To identify cases where approval may have been granted in error, supporting staff education (Correct answer)
- To bill approved cases at a higher rate
- To build a database of patient diagnoses for marketing purposes
- To comply with ICD-10 code assignment requirements
Correct answer: To identify cases where approval may have been granted in error, supporting staff education
Auditing approvals helps identify inappropriate approvals, ensuring consistent and compliant decision-making across all case types.
PACS Continuous Improvement & Updates 2
A prior authorization (PA) team notices that 30% of oncology requests are returned for additional clinical information.
Which continuous improvement action best addresses this systemic issue?