QIO Sanction Committee

9015.1.1 – QIO Sanction Committee (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) To properly identify a violation and determine whether a practitioner or other person has committed a gross and flagrant violation in one or more instances, or a substantial violation in a substantial number of cases, the QIO should convene a Sanction Committee to receive and review all cases initially identified as a violation meeting one of those standards by a QIO peer reviewer. Use of a Sanction Committee ensures that consistent standards and judgment are applied when the QIO identifies a gross and flagrant violation in one or more instances, or a substantial violation in a substantial number of cases. The QIO Sanction Committee should comprise at least three QIO staff and/or board members and include the Review Manager and Medical Director. NOTE: No person who is part of the initial identification of a violation and indicated whether the practitioner or other person has committed a gross and flagrant violation in one or more instances, or a substantial violation in a substantial number of cases—except for the QIO Review Manager and QIO Medical Director - should be a member of the QIO Sanction Panel that attends a requested meeting with the practitioner or other person. Neither shall any individual who was part of the Sanction Committee nor the peer reviewer that identifies a potential violation participate in the final recommendation for the final QIO finding and report to OIG. (See 42 CFR §1004.50.) The QIO Sanction Committee should complete the following: 1. Receive the case upon initial referral from the peer reviewer; 2. Make its recommendation based on all three Physician Reviewers’ determinations. In most cases, this means basing a recommendation on the majority of the determinations; and 3. Complete its review and finding within two (2) business days after the two additional reviews have been completed. • If the QIO Sanction Committee does not identify a violation that meets the reporting threshold, then the original case review process (e.g., beneficiary complaint review, general quality of care review) proceeds in its normal course.  If the QIO Sanction Committee identifies a violation that meets the reporting threshold, then the QIO must notify the CMS Regional Office Contracting Officer’s Representative (COR) within 1 business day after the sanction recommendation is made. (See §9025.2.)