Overview:

Under the 9th SOW, QIOs will continue to carry out statutorily mandated review activities, such as:

Opportunity for Quality Improvement

Individual patient complaints and provider medical record reviews are important starting points for analysis of quality improvement needs among providers. In the 9th SOW, QIOs will be increasing their efforts to link case review activities to improvements in the quality of care, specifically by developing quality improvement activities focused on system-wide changes. QIOs will utilize all data related to case review activities to identify problems related to the quality of care and design quality improvement activities aimed at helping providers correct these problems. The QIOs will be responsible for collaborating with all pertinent CMS contractors to ensure that all available data are considered and to maximize opportunities for quality improvement.

QIO Activities

The activities involved in the Beneficiary Protection Theme will focus on nine Tasks:

In carrying out these activities, QIOs are required to ensure consistency and value and must adhere to CMS policies and procedures. This includes the QIOs’ responsibility to refer cases to the Department of Health and Human Services’ Office for Civil Rights for further investigation if the QIO finds that care is being compromised or denied due to discrimination on the basis of race, color, national origin, disability, or age.

In the 9th SOW, QIOs will now be required to use ADR techniques in appropriate beneficiary complaint cases for which there are no significant concerns about the quality of care provided. ADR options include mediation, facilitated resolution, and external resolution. Mediation involves a mediator in a face-to-face or telephone meeting. Facilitated resolution consists of a QIO facilitator interacting with all parties to generate a resolution or agreement, and does not typically involve a face-to-face meeting. External resolution occurs through direct communication between the provider and the complainant facilitated by the QIO, which follows up to ensure that direct communication occurred and no further review is needed.

With regard to confirmed quality of care concerns, QIOs must follow all CMS instructions. This includes allowing the provider an opportunity for discussion, imposing a corrective action plan where appropriate, and referring cases to the Office of Inspector General (OIG) when a QIO identifies a case in which the provider violates or fails to comply with any obligation in Section 1156(a) of the Social Security Act.

Each QIO must maintain a beneficiary hotline to provide callers with information concerning Medicare beneficiary rights and responsibilities, beneficiary protections, and the various QIO programs and initiatives. The helpline must be staffed during normal business hours with the capability to record calls received outside business hours.

In addition, QIOs must actively promote, and support hospitals in, submission of quality data for reporting and Annual Payment Update (APU) purposes. QIOs must have a basic understanding of all measures, deadlines for submission, and the impact on the APU. QIOs will offer educational and technical assistance to providers on the use of CMS systems and reporting tools such as CART, QualityNet, and the QIO Clinical Warehouse.

Finally, QIOs will continue to fulfill other responsibilities on a regular basis. These responsibilities include physician acknowledgement monitoring, whereby the QIOs ensure that hospitals have a physician acknowledgement statement on file for physicians billing for services provided in the hospital. The QIOs must also work with the Beneficiary Satisfaction Survey Contractor that is surveying beneficiaries regarding their satisfaction with the QIO complaint process. The QIO is responsible for providing complete and timely information to the Survey Contractor. Finally, QIOs must provide an annual public report of all medical service reviews, using a template provided by CMS.

Evaluation

QIOs must complete reviews in a timely manner, with at least 90% of all reviews meeting timeliness standards. QIOs will also be assessed on beneficiary satisfaction. They will be evaluated on the percentage of beneficiaries filing complaints who complete a satisfaction survey and also on the percentage of survey respondents who are satisfied or very satisfied with the complaint process. In addition, QIOs will be assessed on the percentage of QIAs implemented in those cases with confirmed quality of care concerns. For QIAs and both beneficiary performance measures, QIOs will be evaluated by the extent of their improvement each quarter over the baseline value of each measure. Lastly, QIOs will be evaluated on system-wide QIAs, specifically regarding improvements realized as a result of the system-wide change during the 12-month period immediately following the implementation of the activity.

Resources

Medicare QIO Program: www.cms.hhs.gov/QualityImprovementOrgs/
CMS: http://www.cms.hhs.gov/BeneComplaintRespProg/
MedQIC: www.medqic.org (click on “Beneficiary Protection”)

The Medicare QIO Program

Under the direction of the Centers for Medicare & Medicaid Services (CMS), the Quality Improvement Organization (QIO) Program consists of a national network of 53 QIOs, responsible for each U.S. state, territory, and the District of Columbia. QIOs work with healthcare providers, consumers and stakeholder groups to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations. QIOs operate under three-year contracts with CMS, known as Statements of Work (SOWs), the next of which will begin in August 2008 and continue through July 2011.

For more information: www.cms.hhs.gov/QualityImprovementOrgs/