Scope of QIO Fraud and Abuse Review Activities

9200 – Scope of QIO Fraud and Abuse Review Activities (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) In accordance with the QIO contract and 42 CFR Part 476, the QIO must make available the medical expertise necessary to conduct reviews and render quality of care and medical necessity decisions in cases CMS refers to the QIO. The referrals may involve Medicare services in settings other than those normally covered by the QIO reviews. If the QIO identifies possible practice or performance patterns of fraud or abuse situations during its regular case review activity, regardless of whether these situations/issues are within the QIO area of responsibility, the QIO should notify the Federal or State fraud and abuse enforcement agency that has jurisdiction, or in the case of a provider, the appropriate intermediary component pursuant to 42 CFR §480.133. See also 42 CFR §480.137.