Authority for Conducting Quality of Care Reviews

5010 – Authority for Conducting Quality of Care Reviews (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) The statutory and regulatory authority to conduct Quality of Care Reviews is as follows: §1862(g) of the Social Security Act (the Act) requires that the Secretary enter into contracts with QIOs for the purpose of promoting the effective, efficient, and economical delivery of health care services and of promoting the quality of services of the type for which payment may be made under title XVIII. §1154(a) (1) (B) of the Act requires that a QIO conduct review to determine whether the quality of services meets professionally recognized standards of health care. §1154(a)(14) of the Act requires that QIOs conduct appropriate reviews of all written complaints, submitted by beneficiaries or beneficiaries’ representatives, about the quality of services not meeting professionally recognized standards of health care. §1154(a)(4)(A) of the Act requires that each QIO provide that a reasonable proportion of its activities involve reviewing the quality of services under paragraph (a)(1)(B) and that a QIO reasonably allocates such activities among the different cases and settings (including post-acute care settings, ambulatory settings, and health maintenance organizations). 42 CFR §476.71(a) (2) requires a QIO to determine whether the quality of services meets professionally recognized standards of health care. This is accomplished through the resolution of oral beneficiary complaints, written beneficiary complaints, or the completion of general quality of care reviews. 42 CFR §476.71(a) (5) requires the QIO to determine the completeness, adequacy, and quality of hospital care. 42 CFR §476.71(d) requires the QIO to carry out the responsibilities specified in Subpart C of part 1004 related to investigations and referral for sanctions of providers and practitioners who violate statutory obligations under § 1156 of the Act. 42 CFR §476.110 allows the QIO to use immediate advocacy, when the complaint meets certain criteria, to resolve oral beneficiary complaints obtained within 6 months of the date from which the care giving rise to the complaint occurred. 42 CFR §476.120 requires the QIO to conduct a review based on written beneficiary complaints when the care concerning the complaint occurred no more than 3 years from the date when the care giving rise to the complaint occurred, and explains when the QIO can complete a General Quality of Care Review for certain oral beneficiary complaints. 42 CFR §476.130 explains the QIO’s role in reviewing beneficiary complaints, including the scope of the QIO review, medical record requests, types of QIO decisions, and applicable time frames. 42 CFR §476.140 provides the beneficiary and the providers/practitioners with the right to request a reconsideration by the QIO of the initial decision with regard to a complaint , including applicable time frames and issuance of the QIO’s final decision, for complaints filed after July 31, 2014. 42 CFR §476.150 explains the procedures applicable to abandoned beneficiary complaints and for reopening reviews. 42 CFR §476.160 explains the General Quality of Care Review procedures, including applicable time frames, scope of the QIO review, medical record requests, and issuance of the QIO’s written initial determination. 42 CFR §476.170 explains requirements for the General Quality of Care reconsideration process and issuance of the QIO’s final decision.