Beneficiary Protection

The mission of Quality Improvement Organizations (QIOs) is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. QIOs carry out this mission by conducting the following statutorily mandated activities:

• Reviewing the quality of care provided to beneficiaries;
• Reviewing beneficiary appeals of certain provider notices;
• Reviewing beneficiary complaints;
• Reviewing discharges from various provider settings; and
• Assisting providers in the development and implementation of system-wide changes aimed at improving the quality of health care.

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.

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

1. Case reviews
2. Quality improvement activities (QIAs)
3. Alternative dispute resolution (ADR)
4. Sanction activities
5. Physician acknowledgement monitoring
6. Collaboration with other CMS contractors
7. Promoting transparency through reporting
8. Quality data reporting
9. Communication (education and information)

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 adhere to all CMS requirements. 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 CMS Abstraction & Reporting Tool (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.