Rule Includes Major Changes to QIO Program

The U.S. Centers for Medicare & Medicaid Services (CMS) has made a number of important changes to the way Quality Improvement Organizations (QIOs) like IPRO handle quality of care complaints lodged by Medicare beneficiaries. The changes to QIO regulations are included in a massive final rule revising the Medicare hospital outpatient prospective payment system and the Medicare ambulatory surgical center payment program. The changes include long-awaited revisions to the manner in which the organizations disclose review findings to beneficiaries and families; codification of an “immediate advocacy” dispute resolution alternative; new language clarifying that beneficiaries can submit case review requests electronically; and provisions permitting beneficiaries to authorize disclosure of their own confidential medical information.

Historically, QIOs have been barred from disclosing specific information on an adverse quality determination against a physician in the absence of that physician’s agreement to disclose such findings to patients and their families. The new regulation requires QIOs to offer beneficiaries and families detailed findings about practitioner performance without the practitioner’s approval—a change long sought by patient advocacy organizations like Public Citizen and Center for Medicare Advocacy. The final rule was published on November 15 Federal Register; to view the rule, visit