PACS Risk Assessment & Management 4

Question 1

A member's physician requests authorization for a high-cost imaging study but the plan's criteria require a step-therapy trial of a lower-cost alternative first. What type of risk management tool is step therapy?

Accepted Answer

Clinical appropriateness and cost-management protocol

Answer

Step therapy is a clinical appropriateness protocol that manages both quality and cost risk by requiring less intensive or costly treatments before higher-cost options.

Question 2

What is the primary legal risk to a health plan if its prior authorization criteria are not based on current clinical evidence?

Accepted Answer

Exposure to bad faith denial claims and regulatory sanctions

Answer

Using outdated or non-evidence-based criteria exposes a plan to bad faith denial claims and regulatory sanctions for failing to apply sound clinical standards.

Question 3

A prior authorization program shows a 40% overturn rate on appeal. What does this data signal about risk?

Accepted Answer

Initial PA decision criteria may be overly restrictive or improperly applied

Answer

A high overturn rate on appeal suggests initial denial criteria are either too strict or inconsistently applied, creating clinical and legal risk.

Question 4

A hospital submits a prior authorization request with incomplete clinical documentation. Under risk management best practice, what should occur?

Accepted Answer

The reviewer should request the missing information and pause the decision clock

Answer

Best practice is to request missing documentation and pause the decision clock, ensuring a complete clinical review without penalizing the provider or member prematurely.

Question 5

Which scenario most increases the risk of a prior authorization process being found discriminatory?

Accepted Answer

Requiring additional documentation for a specific diagnosis that disproportionately affects a protected class

Answer

Requiring additional documentation for a diagnosis that disproportionately affects a protected class can constitute disparate impact discrimination under civil rights laws.

(PACS) Prior Authorization Certified Specialist Practice Test

(PACS) Prior Authorization Certified Specialist Practice Test

PACS Risk Assessment & Management 4