PACS Risk Assessment & Management 2

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?

Accepted Answer

Cost-based clinical threshold trigger

Answer

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?

Accepted Answer

42 CFR Part 422

Answer

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?

Accepted Answer

Initiate a focused clinical review and provider education program

Answer

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?

Accepted Answer

Denying a medically necessary service that should have been approved

Answer

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?

Accepted Answer

Proactive population health risk stratification

Answer

Proactive population health risk stratification identifies high-risk members in advance so interventions can be deployed before costly events occur.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Risk Assessment & Management 2