PACS Continuous Improvement & Updates 2

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?

Accepted Answer

Develop a disease-specific PA checklist outlining required clinical documentation upfront

Answer

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?

Accepted Answer

Time from PA submission to final determination

Answer

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?

Accepted Answer

Alert the compliance team and update internal reference tools to reflect new criteria

Answer

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?

Accepted Answer

A structured iterative method for testing and implementing process improvements

Answer

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?

Accepted Answer

Perform a root cause analysis to determine if the platform is causing submission errors

Answer

Root cause analysis identifies whether the platform is introducing errors before deciding on a corrective course of action.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Continuous Improvement & Updates 2