PACS Risk Assessment & Management 3 — Questions and Answers
Question 1: A specialist requests prior authorization for an off-label use of a biologic agent. What is the primary risk the PA reviewer must evaluate?
- Network status of the requesting physician
- Clinical evidence supporting safety and efficacy for the off-label indication (Correct answer)
- Whether the drug is available at a retail pharmacy
- The member's deductible status
Correct answer: Clinical evidence supporting safety and efficacy for the off-label indication
Off-label requests require rigorous evaluation of peer-reviewed evidence and clinical guidelines to determine if the use is medically supported.
Question 2: Which metric best measures the downstream risk of a prior authorization program that is too restrictive?
- Average processing time per request
- Rate of emergency department visits following PA denials (Correct answer)
- Number of appeals filed by providers
- Percentage of requests approved on first submission
Correct answer: Rate of emergency department visits following PA denials
An increase in ED visits following PA denials suggests members are forgoing needed care and accessing emergency services instead, indicating the program is too restrictive.
Question 3: Under the ACA's internal appeals requirements, what is the maximum time a health plan has to issue an urgent care prior authorization decision?
- 24 hours
- 72 hours (Correct answer)
- 5 business days
- 14 calendar days
Correct answer: 72 hours
Federal regulations require that urgent care prior authorization decisions be made within 72 hours of receiving the request.
Question 4: A PA coordinator discovers that a physician's office has been submitting duplicate authorization requests for the same service to increase the chance of approval. What category of risk does this represent?
- Clinical quality risk
- Administrative fraud and abuse risk (Correct answer)
- Operational throughput risk
- Network adequacy risk
Correct answer: Administrative fraud and abuse risk
Submitting duplicate requests to game the approval system is an administrative fraud and abuse risk that can trigger compliance investigations.
Question 5: A risk manager is evaluating the plan's PA program after receiving multiple member complaints about delays. What is the first data point to review?
- The plan's medical loss ratio
- Average days to decision compared to regulatory turnaround standards (Correct answer)
- Provider satisfaction scores
- The number of peer-to-peer calls completed
Correct answer: Average days to decision compared to regulatory turnaround standards
Average days to decision compared to regulatory standards directly identifies whether the plan is meeting legally required turnaround times that may be driving complaints.
Question 6: When a health plan delegates prior authorization functions to a vendor, what risk transfer mechanism must be in place?
- A memorandum of understanding outlining communication preferences
- A delegation agreement with audit rights, performance standards, and liability provisions (Correct answer)
- A letter of intent signed by the vendor's medical director
- An informal service-level agreement updated annually
Correct answer: A delegation agreement with audit rights, performance standards, and liability provisions
A formal delegation agreement with audit rights, performance standards, and liability provisions is required to ensure regulatory accountability and operational oversight.
Question 7: Which scenario represents a 'false positive' risk in prior authorization?
- Denying a clinically necessary procedure
- Approving a service that is later found to be medically unnecessary or fraudulent (Correct answer)
- Requiring peer-to-peer review for routine requests
- Miscoding an approved procedure
Correct answer: Approving a service that is later found to be medically unnecessary or fraudulent
A false positive in PA means approving a service that was not medically necessary, which creates financial waste and potential fraud liability.
PACS Risk Assessment & Management 3
A specialist requests prior authorization for an off-label use of a biologic agent.
What is the primary risk the PA reviewer must evaluate?