UPICs and QIOs

4.9.4.2 - UPICs and QIOs (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) Communication with the QIO is essential to discuss the potential impact of efforts to prevent abuse, as well as ensure efforts are made to improve quality of care and access to such care. If potential patient harm is discovered during the course of screening a lead or through the investigation process, the UPIC shall refer those instances to the QIO, state medical board, or state licensing agency. In addition to making the appropriate referrals, the UPIC shall notify the BFL, with a copy to the COR, within two (2) business days once the potential patient harm issue is discovered. If the UPIC refers a provider to the State licensing agency or medical society (i.e., those referrals that need immediate response from the State licensing agency), the UPIC shall also send a copy of the referral to the QIO. If a claim has been reviewed by the QIO, the decision made is final and binding on CMS, and the specific decision rendered by the QIO shall not be overturned by the UPIC.