FROM: Theodore O. Will, FACHE /s/ Chief Executive Officer
DATE: February 18, 2014
RE: CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) CHANGES IN THE QUALITY IMPROVEMENT ORGANIZATION (QIO) BENEFICIARY COMPLAINT AND GENERAL QUALITY OF CARE REVIEW PROCESS
IPRO CONTACT: Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, 516-209-5364
On January 31, 2014, the Centers for Medicare and Medicaid Services (CMS) provided instruction to all Quality Improvement Organizations (QIOs) that we were to implement changes to the QIO beneficiary complaint and general quality of care review processes for complaints/cases received on or after February 1, 2014. The enclosed fact sheet, prepared by CMS, provides an overview of the modifications to the review process as well as information in regard to the Regulation that serves as the basis for these changes.
Please note the following highlights of changes occurring under the new regulations:
For general Quality of Care Reviews which are NOT associated with a beneficiary complaint:
- At the completion of the initial peer review determination, QIOs will notify the provider or practitioner of the results of the review but will no longer offer an opportunity for discussion.
- QIOs will continue to offer the right to reconsideration (previously called a re-review). The reconsideration process will require that the second peer reviewer be a different reviewer than the one who performed the initial review.
For Quality of Care Reviews associated with a beneficiary complaint:
- QIOs will continue to offer an opportunity for discussion. QIOs will also continue to offer the right to reconsideration (previously called a re-review).
- QIOs no longer need physician or practitioner consent in order to share the detailed findings of reviews that result from beneficiary complaints.
Accordingly, for beneficiary complaints received after February 1st, QIOs will include the following information in the written decision provided to the beneficiary or beneficiary representative at the conclusion of the review process:
- Whether or not each concern cited by the beneficiary or beneficiary representative did or did not meet the standard of care;
- Which standard, if applicable, the QIO used to address each of the concern(s); and
- A summary of the specific facts that the QIO determines are pertinent to its decision(s).
In addition, QIOs have been advised to accept written requests from beneficiaries or their designated representative for the release of the detailed review findings on closed complaints in which the physician did not consent to the release of the detailed findings for complaints the QIO received after January 2, 2013. Should this occur, the involved physician/practitioner will be notified and advised that the information is being shared with the beneficiary or the designated representative as a result of changes in the Code of Federal Regulations as explained in the enclosed CMS Fact Sheet.
We encourage you to share this memorandum with your clinicians and medical staff.
Should you have any questions in regard to this memorandum, please feel free to contact Andrea Goldstein.
