CMS Pub. 100-10, ch. 9, § 9015.1.1

To properly identify a violation and determine whether a practitioner or other person has

committed a gross and flagrant violation in one or more instances, or a substantial

violation in a substantial number of cases, the QIO should convene a Sanction Committee

to receive and review all cases initially identified as a violation meeting one of those

standards by a QIO peer reviewer. Use of a Sanction Committee ensures that consistent

standards and judgment are applied when the QIO identifies a gross and flagrant

violation in one or more instances, or a substantial violation in a substantial number of

cases.

The QIO Sanction Committee should comprise at least three QIO staff and/or board

members and include the Review Manager and Medical Director.

NOTE: No person who is part of the initial identification of a violation and indicated

whether the practitioner or other person has committed a gross and flagrant violation in

one or more instances, or a substantial violation in a substantial number of cases— except

for the QIO Review Manager and QIO Medical Director - should be a member of the QIO

Sanction Panel that attends a requested meeting with the practitioner or other person.

Neither shall any individual who was part of the Sanction Committee nor the peer

reviewer that identifies a potential violation participate in the final recommendation for

the final QIO finding and report to OIG. (See 42 CFR §1004.50.)

The QIO Sanction Committee should complete the following:

1. Receive the case upon initial referral from the peer reviewer;

2. Make its recommendation based on all three Physician Reviewers’ determinations.

In most cases, this means basing a recommendation on the majority of the

determinations; and

3. Complete its review and finding within two (2) business days after the two

additional reviews have been completed.

• If the QIO Sanction Committee does not identify a violation that meets the

reporting threshold, then the original case review process (e.g., beneficiary

complaint review, general quality of care review) proceeds in its normal

course.

 If the QIO Sanction Committee identifies a violation that meets the reporting

threshold, then the QIO must notify the CMS Regional Office Contracting

Officer’s Representative (COR) within 1 business day after the sanction

recommendation is made. (See §9025.2.)