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QIO (Quality Improvement Organizations)

Quality Improvments Organizations (QIO)

Overview

The Medicare Quality Improvement Organization (QIO) program was created in 1982 to improve quality and efficiency of services provided to Medicare beneficiaries.  (42 U.S.C. § 1320c, et seq.)  Originally known as Peer Review Organizations, the name was changed to Quality Improvement Organizations to reflect the predominant role of quality measurement and improvement, in addition to the traditional peer review function of the organizations.  The predominant role of QIOs is to review all allegations of EMTALA violations before the Department of Health and Human Services Office of the Inspector General (HHS OIG) imposes civil monetary penalties.  QIOs also still perform peer review of cases in instances where professional standards were not met for purposes of initiating corrective action against Medicare providers. 

By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.  Based on this statutory charge, and CMS's Program experience, CMS identifies the core functions of the QIO Program as:

  • Improving quality of care for beneficiaries;
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
  • Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

CMS Contracts with QIOs

CMS contracts with one QIO in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction's QIO contractor.  (http://www.cms.hhs.gov/QualityImprovementOrgs/01_Overview.asp)  QIOs are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to: 

  1. Review medical care;
  2. Help beneficiaries with complaints about the quality of care; and
  3. Implement improvements in the quality of care available throughout the spectrum of care provided by Medicare. 

QIO contracts are three years in length, with each such three-year contract cycle referred to as a scope of work ("SOW"). 

Scope of Work

 

The Medicare QIO Program has periodically identified areas it intends for the QIOs to focus on during the three years of the upcoming SOW.  For example, the eighth SOW, effective beginning in August 2005, identified necessary clinical and non-clinical measures in nursing homes, home health agencies, and hospital and physician services in addition to the QIO’s consistent role of measuring and protecting services to beneficiaries. 

The QIO Program is currently working under the ninth SOW.  A major theme of the ninth SOW is Care Transitions, which aims to measurably improve the quality of care for Medicare beneficiaries who transition among care settings through a comprehensive community effort.  One strategy tool being implemented in the ninth SOW is the Internet-based, standardized assessment instrument, referred to as CARE (Continuity Assessment Record and Evaluation).  (See http://www.cms.hhs.gov/QualityImprovementOrgs/Downloads/CareFactSheetQIO.pdf.) 

Conclusion

Though there has been evolution in the focus and role of QIOs since their genesis in 1982, their primary aim continues to be the protection of the quality and efficiency of services provided to Medicare beneficiaries.  Through the varying emphases of the SOWs, the QIO Program evolves to meet emerging areas of concern in beneficiary protection. 

Acknowledgement

AHLA would like to thank ____________ for drafting this article and ________ for able editorial assistance.