Referrals to the Quality Improvement Organization (QIO)

6.6 - Referrals to the Quality Improvement Organization (QIO) (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) The MACs shall only refer Quality of (Health) Care Concerns to the QIOs. A Quality of (Health) Care Concern is defined as “a concern that care provided did not meet a professionally recognized standard of health care.” The Contractor shall follow the referral process as agreed upon in the QIO-MAC Joint Operating Agreement. The QIOs will retain their responsibility for performing expedited determinations, Hospital-Issued Notices of Non-Coverage (HINN) reviews, quality reviews, transfer reviews, readmission reviews and, provider-requested higher-weighted DRG reviews. The Circumvention of PPS will continue to be reported to your UPIC. The quality initiatives associated with payment for performance are now the reporting source for Readmission Reviews and Transfer Review data to the QIOs. Non-covered benefits/services are not to be reported to the QIO. All initial payment determinations and claim adjustments are required to be performed by the MAC. All MACs are to turn off all automated edits/processes that generate a referral to the QIOs prior to a medical record review of the claim. Referrals to the QIO shall be limited to Quality of Health Care issues as defined above and shall result from a clinician’s medical record review of a provider’s medical documentation. If during the medical record review process, “a concern that care provided did not meet a professionally recognized standard of health care,” the MAC shall issue a payment determination and/or adjustment for the claim, complete the QIO referral form, and forward the completed referral form and file(s) to the QIO. If the referral form is not complete, the QIO will return the file to the MAC and request that the MAC provide the missing information prior to the QIO performing a review. A non-covered service and/or procedure shall not be automatically referred to the QIO. The MAC shall make the initial payment determination and/or claim adjustment for a non-covered service or procedure in accordance with the Medicare IOM 100-04, Claims Processing Manual and IOM 100-02, Benefit Policy Manual. If during the medical record review process, “a concern that care provided did not meet a professionally recognized standard of health care,” such as a medically unnecessary procedure, the claim shall be referred to the QIO for quality review after payment determination and/or claim adjustment is made. The MACs shall not instruct providers, suppliers, or beneficiaries to refer payment issues to the QIO. If the provider or supplier does not agree with the payment and/or claim adjustment decision, the MAC shall communicate their options to follow the current process in IOM 100-08, requesting a reopening or an appeal. If the beneficiary disagrees with the payment decision and makes a request for re-evaluation/redetermination, this will be considered a demand bill and is the responsibility of the MAC.