QIO Program Purpose

1005 - QIO Program Purpose (Rev. 19, Issued: 05-01-15, Effective: 05-01-15, Implementation: 05-01-15) CMS contracts with QIOs to perform core functions that include case review and quality improvement. Sections 1152 and 1153(a), (b), (c), and (e) of the Social Security Act and 42 CFR Part 475.101 through 475.103 define requirements for an entity to be awarded a contract to perform QIO functions. The case review functions of a QIO include review of healthcare services and items for which payment is made under Medicare Parts A, B, C, or D to determine whether services or items are reasonable, medically necessary, and allowable, meet professionally recognized standards of care, or in the case of inpatient care, could be provided more economically on an outpatient basis or in an inpatient facility of a different type. Generally, case reviews must be performed by a healthcare practitioner in the same professional field as the healthcare practitioner who ordered or furnished the services under review. The QIO must perform case review functions as outlined in 42 CFR Part 476 and as defined in its contract with CMS. Other chapters of this manual provide more specific guidance on the various case review functions. Quality improvement functions may include technical assistance, data analysis, and stakeholder engagement activities that promote evidence-based healthcare practice and patient-centered care principles to improve healthcare quality of care, improve outcomes to beneficiaries, and lower costs. The QIO must perform quality improvement functions consistent with the terms of its contract with CMS. Quality improvement functions may include, but are not limited to, the following: • Engaging patients, families, and care-givers with the goal of increasing patient knowledge, skill, and confidence to take an active role in managing their health and healthcare • Technical assistance related to CMS quality measures across settings to help providers and practitioners meet standards An activity designed to serve as a catalyst and support for quality improvements that may relate to safety, healthcare, health, and value, and involve providers, practitioners, beneficiaries, and/or communities