QIO Role and Responsibilities

9015.1 – QIO Role and Responsibilities (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The QIO may identify a potential violation for peer review through individual case reviews, including beneficiary complaints and other general quality of care reviews (see 42 CFR 476 and the QIO Manual Chapters that address quality of care reviews.). Quality of care issues may also be referred from other QIOs and other agencies for review by a QIO physician peer reviewer. (See Chapter 5.) This includes Medicare Administrative Contractors (MACs), Medicare health plans(MHPs), State survey and certification agencies (SSA), other CMS contractors, CMS, as well as other Federal Government organizations outside of CMS (e.g. the Office of Inspector General, Department of Justice [DOJ], or Office for Civil Rights), The QIO is responsible for ensuring that the sanction process and plan is followed in accordance with applicable law, including 42 CFR 480, which addresses confidentiality and disclosure requirements. (See also QIO Manual Chapter 10.) The QIO has the following responsibilities: (1) Use its authority or influence to enlist the support of other professional or government agencies to ensure that each practitioner or other person complies with the obligations specified in §1156(a) and 42 CFR §1004.10. (2) Based on case reviews the QIO conducted (see 42 CFR part 476) and referrals from other entities, preliminarily identify situations where an obligation specified in 42 CFR §1004.10 is violated and identify whether the violation meets the standard for reporting to OIG. (3) Provide notice to the practitioner or other person of the preliminary finding and an opportunity for discussion. (4) If appropriate, provide an opportunity (and a suggested method) for correcting the situation and a time period for a corrective action. (See 42 CFR §1004.40.) (5) Make a final finding: • To close the case where no violation has been found to be a gross and flagrant violation or where no substantial violation is identified in a substantial number of cases; • That the violation has been resolved based on satisfactory compliance with the corrective action plan; or • To affirm or modify the initial finding that a violation is gross and flagrant or a substantial violation in a substantial number of cases, which must be reported to OIG. (6) After making a final finding, report to OIG, in the form and manner required by 42 CFR §1004.80, if the QIO finds that the practitioner or other person has: (A) Failed substantially to comply with any obligation in a substantial number (three or more) of admissions; or (B) Grossly and flagrantly violated any obligation in one or more instances. (7) Issue denial of payment for services or items furnished or ordered (or at the medical direction or on the prescription of an excluded physician) by an excluded practitioner or other person when the QIO identifies such services or items. NOTE: The QIO must report the findings to CMS. NOTE: The “reporting threshold” is when the practitioner or other person has either: (a) failed substantially to comply with any obligation in a substantial number (three or more) of admissions; or (b) grossly and flagrantly violated any obligation in one or more instances.