QIO Review Responsibilities – 60-Day Review

9135 – QIO Review Responsibilities – 60-Day Review (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The Regional Office DSC will notify the QIO of EMTALA cases that it is referring to OIG. Before OIG can assess a CMP or exclude a physician from the Medicare program, the QIO must review the case and provide a report of the findings to the originating Regional Office, which is responsible for forwarding the report to OIG. The QIO review includes offering the involved physician(s) and hospital(s) an opportunity to discuss the case and to submit additional information before OIG may impose sanctions. For the 60-Day EMTALA Review Process, the QIO will follow the Physician Peer Review five (5)-day EMTALA Review Process described in §9130.2. In addition, the following instructions also apply for the 60-day review process. The QIO must provide a written notice of the opportunities to the affected physician/hospital (see 42 CFR §489.24(h)(2)) and arrange the meeting either by telephone or face-to-face. The letter should identify the name of the individual and the date he/she presented to the emergency room. (See Appendix 9-16, 60-Day QIO Review- Opportunity for Discussion Model Letter.) Notify OIG at the appropriate CMS Regional Office of the time and date the hospital and, if applicable, the physician are meeting with the QIO, or notify OIG that the hospital and, if appropriate, the physician have declined the opportunity to do so. The hospital and/or the physician have the right to legal counsel present during the meeting. However, the QIO may control the attorney’s scope, extent, and manner of any questioning or any other presentation. The QIO may also have legal counsel present. The QIO may reasonably limit the number of witnesses and length of testimony if such testimony is irrelevant or repetitive. The QIO is not obligated to consider any additional information that the hospital and/or the physician submit after the meeting, unless the QIO requests them to submit additional information to support their assertions before the end of the meeting. In this case, the QIO provides the hospital and/or the physician additional time, not to exceed five (5) calendar days from the meeting, to submit the relevant information. The QIO is required to keep a recording of the hospital and/or practitioner meeting. However, it is not necessary to hire a professional stenographer to produce a written transcript of the meeting. An audio recording is acceptable unless a written transcript subsequently is requested by CMS Regional Office DSC or OIG. If the hospital and/or practitioner(s) elect to discuss the case with the QIO during a formal meeting, the QIO and physician peer reviewer WILL NOT provide a clinical opinion about the case during this meeting. If the hospital and/or practitioner request a copy of the QIO physician peer review five (5)-day review results, they should be directed to contact the CMS Regional Office DSC, which is responsible for addressing and fulfilling all requests for documents from the hospital and/or physician involved in the case. Considering all the information on the case, the QIO sends its 60-day physician review worksheet along with pertinent documentation to the Regional Office DSC, who will forward a copy to OIG.