Agreements with Providers of Services

3005 Agreements with Providers of Services (Rev.29, Issued: 10- 21-16, Effective: 10-21-16, Implementation 10-21-16) MOAs with providers of services (i.e., hospitals, CAHs, SNFs, HHAs, CORFs, and hospices) should address the statutory activities (Sections 1154(a)(1), 1154(a)(4)(A), 1154(a)(14), 1866(a)(F)(i), 1866(a)(F)(ii), and 1866(a)(3)(A) of the Act), as well as those activities required by CMS in the QIO contract. Providers must furnish patient care data including patient medical records requested by a QIO to perform the reviews specified in the QIO contract (See 42 CFR 476.78 (a) and (b)). Results of QIO case reviews may include denial of payment for admission, DRG changes, and the identification of confirmed quality of care concerns. At a minimum, the MOA must include the QIO’s responsibilities and the responsibilities of the provider regarding the following, if applicable: • Case Review -- Identify requirements for provider compliance in furnishing data and information necessary for QIO case reviews to determine whether the services were reasonable and medically necessary and furnished in the appropriate setting, and whether they met professionally recognized standards of care. • Data Analysis -- Review of individual patient care data furnished by providers to ensure the validity of all diagnostic and procedural information. • Claims Analysis -- Review of payment data to determine whether payment must be made for the services furnished (as appropriate). • Complaint Analysis -- Review of cases in response to written beneficiary complaints about the quality of services. • Confidentiality and Disclosure -- Include confidentiality and disclosure requirements in all agreements in accordance with 42 CFR Part 480. • Beneficiary Rights Outreach and Education Activities -- Conduct programs to inform Medicare enrollees about QIO review programs, the role of a QIO, grievance and complaint procedures, confidentiality and disclosure rights and notice requirements. • Timing of Review -- Conduct review within the timeframes specified in the QIO contract between CMS and the QIO. • Location of Review -- Specify all locations where QIO review of cases may take place (e.g., at the QIO or on-site review at the provider’s facility). • Quality Improvement Initiative (QII) Referrals-- Specify the process for the referral of confirmed quality of care concerns identified by a QIO that conducts case review to another QIO entity in the service area that is responsible for conducting quality improvement initiatives. • Miscellaneous -- Identify additional review activities and procedures as prescribed by CMS in the QIO contract. QIOs may also want to include language to address the exchange of information with the MAC, Clinical Data Abstraction Center (CDAC), CMS, Office of the Inspector General (OIG), and State agency referrals in the MOA. Signature Requirements Both parties must sign the MOA. If a provider refuses to sign the MOA, the QIO must inform the CMS Contracting Officer Representative (COR) of this matter. MOA Modifications QIOs and providers of services may modify MOAs when changes in contract requirements necessitate changes between the QIO and the provider. Representatives of the QIO and the provider organization must sign the revised MOA. Failure to Return, Sign, or Honor the Terms of a MOA If a provider fails to return the MOA by the requested due date, refuses to sign the MOA, or fails to honor the provisions of the MOA, the QIO should document the efforts taken to resolve the issues and obtain a signed MOA and refer the circumstances to the COR for resolution.