PACS Enforcement Actions & Penalties 2

Question 1

A health plan repeatedly denies prior authorization requests without providing the required written notice. Under ERISA, what enforcement mechanism can plan participants use?

Accepted Answer

Sue in federal court under ERISA Section 502(a)

Answer

ERISA Section 502(a) allows plan participants and beneficiaries to bring civil actions in federal court to enforce plan terms and recover benefits.

Question 2

Which federal agency has primary authority to investigate and penalize Medicare Advantage plans that improperly deny prior authorization requests?

Accepted Answer

Centers for Medicare & Medicaid Services (CMS)

Answer

CMS has direct regulatory authority over Medicare Advantage plans and can impose civil monetary penalties, compliance actions, or contract terminations for PA violations.

Question 3

A utilization review entity fails to use board-certified physicians to review prior authorization denials for complex surgical procedures. This most likely violates which type of requirement?

Accepted Answer

Clinical reviewer credential standards

Answer

Most state UR laws and accreditation standards require that adverse determinations for complex clinical matters be reviewed by appropriately credentialed physicians.

Question 4

Under the No Surprises Act, what penalty can health plans face for failing to comply with the required prior authorization transparency disclosures?

Accepted Answer

Civil monetary penalties up to $100 per day per violation

Answer

The No Surprises Act authorizes civil monetary penalties of up to $100 per day per individual for violations of its transparency and disclosure requirements.

Question 5

A state insurance commissioner finds that a health insurer's PA denial rate for mental health services is disproportionately higher than for comparable medical services. This triggers enforcement under which law?

Accepted Answer

Mental Health Parity and Addiction Equity Act (MHPAEA)

Answer

MHPAEA prohibits health plans from applying more restrictive prior authorization criteria to mental health and substance use disorder benefits than to comparable medical/surgical benefits.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Enforcement Actions & Penalties 2