CMS Pub. 100-10, ch. 9, § 9035.2

A majority vote of the peer reviewers who are members of the QIO Sanction Panel makes

the determination.

The QIO peer reviewer who was responsible for the medical judgment and development of

the initial finding of a potential violation that triggers a referral of a practitioner or other

person to the QIO for sanction (i.e., the peer reviewer responsible for the referral to the

QIO Sanction Committee) may not vote on the recommendation at a meeting of the QIO

Sanction Panel.

The reviewers who complete additional reviews and provide input to the Sanction

Committee (see §9025.1) may also not vote on the recommendation at a meeting of the

QIO Sanction Panel. Such individuals may be present at the meeting.

The actions the QIO Sanction Panel may take as a result of the additional information are

as follows:

a. Deferment of Finding: The Sanction Panel may accept or suggest a proposed

method of corrective action and timeframe for completion. (See §9035.3 below.)

Should this occur, a final QIO finding (of violation and recommended sanction) is

not made until the appropriate amount of time has elapsed for re-evaluation of the

physician or provider.

o If the corrective action is not taken within the specified timeframe, if a

timeframe and/or corrective action cannot be agreed upon, or if previous

corrective action plan(s) have been unsuccessful, and a gross and flagrant

violation or a substantial violation in three or more instances is confirmed,

deferment is not an option.

o If the finding is resolved to the QIO’s satisfaction, the QIO may either (a)

modify the initial finding and recommendation or (b) close the case as

resolved.

b. Reversal of Initial Finding: If the Sanction Panel members believe the additional

information presented is sufficient and that the reporting threshold has not been

met, one of the following actions can be taken:

1. The initial finding is reversed/resolved; or

2. The Panel may determine an alternate method of corrective action and

follow-up should problems remain evident that does not meet the

definitions of “gross and flagrant” or “substantial.” The P anel will

forward these confirmed quality of care concerns to the QIO’s Quality

Improvement Committee/Department for monitoring or other action.

c. Affirmation of Initial Finding: The Sanction Panel may decide to uphold (in

whole or in part) the initial finding of a violation and take one of the following

actions:

1. Refer to OIG immediately. See §9040 below; or

2. Recommend a written Corrective Action Plan. See §9035.3 below.

If the QIO determines, after careful consideration, that implementation of a CAP would

not be appropriate, the QIO should carefully document the rationale for the decision and

include this documentation in the report to OIG.

Written notice of the QIO action taken must be provided to the practitioner or individual

under review. (See 43 CFR §1004.60(b).)