PACS Enforcement Actions & Penalties 3

Question 1

Under California's Knox-Keene Act, health plans that fail to comply with prior authorization timelines may face fines of how much per violation?

Accepted Answer

Up to $10,000 per day per violation

Answer

California's Department of Managed Health Care can impose fines up to $10,000 per day per violation for health plan failures, including PA timeline non-compliance.

Question 2

A utilization management company is found to have financial incentives that reward reviewers for denying prior authorization requests. This practice most directly violates which principle?

Accepted Answer

Independence of utilization review

Answer

UM regulations require that reviewer decisions be based solely on clinical criteria and prohibit compensation structures that create incentives to deny coverage.

Question 3

Which of the following best describes a 'pattern of practice' violation in the context of prior authorization enforcement?

Accepted Answer

Repeated systematic failures that demonstrate a course of conduct rather than isolated errors

Answer

Pattern of practice violations involve repeated, systematic failures rather than isolated incidents and typically attract more severe regulatory scrutiny and penalties.

Question 4

Under URAC accreditation standards, a health plan that loses its accreditation due to PA process failures faces which immediate consequence?

Accepted Answer

Loss of ability to market compliance with URAC standards to employers and payers

Answer

URAC accreditation is voluntary, but losing it means the organization can no longer represent itself as URAC-accredited, which can affect contract opportunities and credibility.

Question 5

A patient is harmed after a health plan wrongfully denies PA for emergency surgery. Under state tort law, which theory of liability is most likely to apply to the plan?

Accepted Answer

Bad faith denial of benefits

Answer

Bad faith denial of benefits is a recognized tort in many states where a plan unreasonably denies or delays authorization, especially when harm results.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Enforcement Actions & Penalties 3