QIO 5-Day Review Responsibilities

9130 – QIO 5-Day Review Responsibilities (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) If the Regional Office DSC finds that the case involves a possible violation of §1867 and this determination rests wholly or in part on the clinical aspects of the case, the DSC must consult with the QIO before determining whether the hospital has violated EMTALA, unless delaying to obtain a QIO review would jeopardize the health or safety of individuals. Clinical aspects of the case may include questions such as whether the individual had an emergency medical condition, whether there was an appropriate medical screening examination, whether a hospital had the capability to provide stabilizing treatment, whether an individual’s emergency medical condition was stabilized, whether a transfer was appropriate, whether a recipient hospital had the required capability and capacity to provide stabilizing treatment, and any other questions as necessary. In reviewing cases, the QIO physician reviewer should consider information that the treating physician: 1. Had, could have had, and should have had available to him/her at the time of the individual's visit; and 2. Could have discovered reasonably and which was necessary to adequately care for the individual (e.g., the physician should have conducted an adequate history interview) at the time of the individual’s visit. The Regional Office DSC may also require the QIO to participate in an informal discussion that the Regional Office sets up with the affected physician/hospital to discuss the case. NOTE: CMS has the authority and responsibility to determine whether the law has been violated. The QIO physician reviewer MUST NOT state an opinion about whether a violation has occurred.