QIO Physician Review Process Description

9135.2 – QIO Physician Review Process Description (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) 9135.2.1 – 60-Calendar-Day Timeframe (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) The timeframe is as follows: Calendar Day 1: The QIO receives the record from the CMS Regional Office DSC. Calendar Day 15: Notify the involved hospital and, if appropriate, the involved physician via certified letter, return receipt requested. The letter should inform the hospital and/or physician that the QIO is reviewing the case as well as the opportunity to discuss the case (in person or by phone). Inform the hospital/physician that they may submit additional information within 30 calendar days of receiving the letter. (See Appendix 9-16, 60-Day QIO Review-Opportunity for Discussion Model Letter.) The letter must also contain: • The name of each individual who is the subject of the violation; • The date on which each violation occurred; • A statement that the rights to discuss the case and provide additional information will be waived if the invitation is not accepted; and • A copy of 42 CFR §489.24. When a meeting is scheduled, notify the Regional Office DSC and OIG of the time and date. Calendar Day 20: The above letter(s) is (are) presumed to have been received by the hospital and/or physician. Calendar Day 50: Discussion and hospital/physician submission of data, if desired, is complete. Calendar Day 60: The QIO completes the review. The Regional Office DSC must receive the QIO final physician review and report (facsimile or through a secure electronic system approved by CMS) no later than close of business on calendar day 60. If submitted electronically, a signed hard copy must be sent to the DSC by mail. The QIO 60-day report must contain: • The name of the hospital or physician (or both, where applicable); • The name of the individual and the dates and times the individual arrived at and was transferred (or discharged) from the hospital; and • The completed QIO physician review worksheet. NOTE: Do not state an opinion or conclusion about whether a violation has occurred.