PACS Risk Assessment & Management 2 — Questions and Answers
Question 1: A payer's prior authorization policy requires additional clinical review when a requested service exceeds a cost threshold. What is this type of risk control called?
- Concurrent review
- Prospective utilization management
- Cost-based clinical threshold trigger (Correct answer)
- Retrospective denial
Correct answer: Cost-based clinical threshold trigger
Cost-based clinical threshold triggers are risk controls that initiate enhanced review when a service cost exceeds a defined limit.
Question 2: Which federal regulation most directly governs the risk that a Medicare Advantage plan faces when denying prior authorization requests?
- HIPAA Privacy Rule
- 42 CFR Part 422 (Correct answer)
- The Employee Retirement Income Security Act
- The False Claims Act
Correct answer: 42 CFR Part 422
42 CFR Part 422 establishes CMS rules for Medicare Advantage plans, including standards for prior authorization denials and appeals.
Question 3: A health plan identifies that a provider is submitting prior authorization requests for procedures with a high rate of post-service adverse outcomes. What risk management step is most appropriate?
- Automatically deny all future requests from this provider
- Initiate a focused clinical review and provider education program (Correct answer)
- Remove the provider from the network immediately
- Report the provider to the state medical board
Correct answer: Initiate a focused clinical review and provider education program
A focused clinical review and provider education addresses the quality risk while maintaining the care relationship and due process.
Question 4: What does 'false negative' risk mean in the context of prior authorization?
- Approving a medically necessary service that later causes harm
- Denying a medically necessary service that should have been approved (Correct answer)
- Incorrectly coding an approved service
- Approving a fraudulent claim
Correct answer: Denying a medically necessary service that should have been approved
A false negative in PA means the system incorrectly denied a service that was clinically appropriate, creating access-to-care and liability risk.
Question 5: An insurer uses predictive modeling to flag high-cost members before they request services. This is an example of which risk management approach?
- Reactive risk mitigation
- Proactive population health risk stratification (Correct answer)
- Retrospective claims auditing
- Concurrent case management
Correct answer: Proactive population health risk stratification
Proactive population health risk stratification identifies high-risk members in advance so interventions can be deployed before costly events occur.
Question 6: When assessing authorization risk for a new specialty drug, which factor carries the MOST clinical weight?
- The drug's list price relative to the plan's budget
- Evidence-based clinical guidelines and FDA-approved indications (Correct answer)
- The prescribing physician's specialty
- The member's geographic location
Correct answer: Evidence-based clinical guidelines and FDA-approved indications
Evidence-based clinical guidelines and FDA-approved indications are the primary clinical benchmarks for evaluating specialty drug authorization requests.
Question 7: A prior authorization specialist notices that denial letters for behavioral health services are less detailed than those for medical services. What compliance risk does this create?
- ERISA reporting violations
- Mental Health Parity and Addiction Equity Act (MHPAEA) violations (Correct answer)
- COBRA notification failures
- Medicare Part D formulary violations
Correct answer: Mental Health Parity and Addiction Equity Act (MHPAEA) violations
MHPAEA requires that denial criteria and processes for behavioral health be no more restrictive than for comparable medical/surgical benefits.
PACS Risk Assessment & Management 2
A payer's prior authorization policy requires additional clinical review when a requested service exceeds a cost threshold.
What is this type of risk control called?