QIO Fraud and Abuse Review Process

9210.2 – QIO Fraud and Abuse Review Process (Rev. 24, Issued: 02-12-16, Effective: 03-14-16, Implementation: 03-14-16) When the QIO receives a referral or request for a fraud and abuse review, the QIO should notify the CMS COR. For these cases, the QIO will investigate the issues and decide on any matters involving medical necessity or quality of care. The QIO should provide written evaluations of all cases to CMS or the outside agency, as appropriate, within 45 calendar days of receiving the referral or within the timeframe agreed upon between the QIO and CMS. Physician reviewers should be board-certified (although this is not required) and actively practicing in the same specialty or specialties as the physician who treated the patient whose case resulted in the review. In addition, whenever possible, the physician reviewer should practice in a setting similar to that of the physician who attended the patient. CMS or the outside agency will ensure that all relevant case materials are available to the QIO on the day the case is referred for investigation. Therefore, the entire 45 days is available for the QIO to complete the review.