Quality Improvement Initiative Not Needed

5125.2.4 – Quality Improvement Initiative Not Needed (Rev. 28, Issued: 10-21-16, Effective: 10-21-16, Implementation: 10-21-16) Under the Quality Innovation Network-QIO contracts, QIOs have the authority to pursue QIIs in all situations where quality of care concerns are confirmed but a referral for sanction or Corrective Action Plan covered in Manual Chapter 9 is not appropriate. However, there are situations where a QII may not be appropriate. For example: • A case is referred to a Federal or State enforcement agency responsible for the investigation or identification of fraud or abuse of the Medicare program. • The practitioner(s) and/or provider(s) provide evidence that the concern(s) is a single, isolated instance and does not effectively allow for improvement. • The underlying concern has already been identified and action taken to correct the problem (e.g., a Medicare coder who has been making numerous errors has been retrained and is now performing well). • The concern(s) will be resolved by a QII that has already been initiated. • The source of the concern is a physician, and the physician has retired, expired, or moved his/her practice out of the State. NOTE: When a practitioner has moved his/her practice out of State while a Quality of Care Review, Sanction Review under Part 1004, or Corrective Action Plan is pending, the QIO must forward any pertinent information to the QIO in the new State of practice. The appropriate COR must be provided with pertinent information related to the forwarding of concerns between QIOs.