CMS Pub. 100-10, ch. 1, § 1010

Only those entities that hold a contract with CMS to perform as a QIO are QIOs. QIOs

perform a function or functions defined in Section 1154(a) of the Social Security Act (42

U.S.C. 1320c-3(a)) in accordance with the terms that CMS defines in its QIO contracts.

QIO contracts may require performance of one or more functions governed by statute as

defined in 42 U.S.C. 1320c-3(a)(1) through (18). These statutory responsibilities may

include the following:

1. Review the provision of health care services and items for which payment may be

made. Involve healthcare practitioners of the type under review in such reviews.

Determine through review whether services were reasonable and medically

necessary, meet professionally recognized standards, and, if provided in an

inpatient setting, could be provided more economically on an outpatient basis or

in an inpatient facility of a different type. (42 U.S.C. 1320c-3(a)(1))

2. Determine, on the basis of the review described above, whether payment shall be

made, provided that determinations to deny payment because the quality of care

did not meet professional standards are based on criteria developed by the

Secretary (42 U.S.C. 1320c-3(a)(2))

3. Notify the healthcare provider, patient, and the agency or organization

responsible for the payment of claims of the review determination within specific

parameters (42 U.S.C. 1320c-3(a)(3))

4. Conduct a reasonable proportion of quality of service reviews among the different

cases and settings. Review both inpatient and outpatient services provided by

Medicare cost plans under section 1876 pursuant to a risk-sharing contract.

Maintain a beneficiary outreach program designed to apprise individuals

receiving care under Medicare health plans of the QIO program. (42 U.S.C.

1320c-3(a)(4))

5. Consult with nurses and other professional healthcare practitioners and

providers of healthcare services with respect to the organization's responsibility

for the review of the professional activities of such practitioners and providers

(42 U.S.C. 1320c-3(a)(5))

6. Apply professionally developed norms of care, diagnosis, and treatment. Provide

a physician representative to meet several times a year with medical and

administrative staff of each hospital whose services are reviewed by the

organization. Publish not less often than annually its review findings. (42 U.S.C.

1320c-3(a)(6))

7. Utilize the services of persons who are practitioners of, or specialists in, the

various areas it reviews, make professional inquiries, examine pertinent records,

and inspect facilities in support of its reviews (42 U.S.C. 1320c-3(a)(7))

8. Carry out reviews to approve exceptions to the payment exclusion for assistants at

surgery in a cataract operation as specified in Section 1862(a)(15) of the Social

Security Act (42 U.S.C. 1320c-3(a)(8))

9. Collect, maintain, and permit access to information relevant to its functions and

notify appropriate state boards in the event of a violation of section 1156(a) (42

U.S.C. 1320c-3(a)(9))

10. Coordinate activities for economical and efficient operation of the program (42

U.S.C. 1320c-3(a)(10))

11. Make available its facilities and resources for contracting with private and other

public entities that pay for health care to provide similar review services (42

U.S.C. 1320c-3(a)(11))

12. Review ambulatory surgical procedures specified pursuant to section

1833(i)(1)(A) of the Social Security Act (42 U.S.C. 1320c-3(a)(12))

13. Review early readmission cases (42 U.S.C. 1320c-3(a)(13))

14. Review all written complaints from Medicare beneficiaries about the quality of

services (42 U.S.C. 1320c-3(a)(14))

15. Perform on-site reviews (42 U.S.C. 1320c-3(a)(15))

16. Upon request from the Secretary or CMS pursuant to section 1867(d) of the Act,

review hospital and physician performance for compliance with the Emergency

Medical Treatment and Labor Act (42 U.S.C. 1320c-3(a)(16))

17. Offer quality improvement assistance pertaining to prescription drug therapy to

providers, practitioners, and Medicare health plans (42 U.S.C. 1320c-3(a)(17))

18. Perform activities deemed necessary by the Secretary for purposes of improving

the quality of care (42 U.S.C. 1320c-3(a)(18))

In order to fulfill these statutory responsibilities, QIOs may perform activities that

include, but are not limited to, the following:

• Establishing methods and procedures for involvement of healthcare practitioners in

performing reviews of healthcare services and investigating complaints

• Maintaining current knowledge of Medicare programs in order to conclusively

determine whether payments must be made for services under Title XVIII of the

Social Security Act

• Entering into Memoranda of Agreement with healthcare providers, payers, and other

organizations prior to conducting Medicare case reviews in the service areas and for

the types of cases it will have authority to review, and conducting outreach to inform

beneficiaries about how to exercise their right to QIO reviews

• Establishing procedures for notifying any patient, practitioner, provider, and any

organization responsible for payment to communicate with them about the QIO

review determination and rights to reconsideration or appeal

• Planning for and maintaining sufficient staffing to assure that resources are allocated

to performing reviews by duly licensed professionals for all of the different cases and

settings

• Establishing methods for identifying cases where there is a likelihood that quality of

services do not meet professionally recognized standards of care

• Coordinating activities and information exchanges across QIO contractors and

Program stakeholders such as public and private organizations involved in

healthcare delivery

• Publishing at least annually a report of QIO activities and findings

• Performing any other services to improve the quality of care for services under Title

XVIII of the Social Security Act that CMS determines are appropriate for

performance under QIO contract awards

• Maintaining procedures to continuously monitor, mitigate, or avoid any actual,

potential, or apparent conflicts of interest of the QIO organization, its employees and

subcontractors when performing any function of the QIO contract

Section 1153 of the Social Security Act requires that CMS ensure there is no duplication

of the functions carried out by QIOs if more than one QIO operates in the same area.

QIO contractors should assist CMS and work together with other stakeholders to identify

and mitigate any duplication of effort identified in their geographic or service area.