Quality Improvement Organizations (QIO)

CMS has announced that it is allowing Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) to resume initial patient status reviews to determine the appropriateness of Part A payment for short stay inpatient hospital claims, effective September 12, 2016.  Such reviews had been “paused” since May 4, 2016 to promote consistent application of

CMS has temporarily “paused” Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations’ (QIOs) performance of initial patient status reviews under CMS’s “two-midnight policy” for short hospital stays. The pause, which took effect May 4, 2016, was a result of inconsistencies in the BFCC-QIOs’ application of the two-midnight policy and was intended to give CMS

On July 8, 2015, the Centers for Medicare & Medicaid Services (CMS) published its proposed rule to update the Medicare Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment System rates and policies for calendar year (CY) 2016.  Perhaps most notably, CMS is proposing a -0.1% OPPS update for 2016, driven mainly by a proposed correction of a $1 billion error the agency made when estimating the extent to which clinical laboratory tests would be packaged (rather than paid separately) under a new policy implemented in 2014. Specifically, the proposed -0.1% update reflects a 2.7% market basket increase, which is partially offset by a -0.6% multifactor productivity (MFP) adjustment and an additional 0.2% reduction (both mandated by the Affordable Care Act), further reduced by a -2.0 percentage point adjustment to recoup the prior $1 billion overestimation of laboratory test packaging. CMS expects that overall OPPS payments under the proposed rule would fall by 0.2%, or $43 million, compared with 2015 levels. Hospitals that fail to meet the Hospital Outpatient Quality Reporting (OQR) Program reporting requirements are subject to an additional reduction of 2.0 percentage points. The actual update for individual procedures can vary dramatically, however. Other highlights of the proposed rule include the following:
Continue Reading CMS Proposes $43 Million CY 2016 Medicare OPPS Rate Cut; Small Increase in ASC Payments

The OIG recently issued a report that examined the extent to which Quality Improvement Organizations (QIOs) duplicate other CMS hospital quality improvement efforts, particularly Hospital Engagement Networks (HENs) and the Community-Based Care Transitions Program (CCTP). Based on a questionnaire sent to a random sample of 410 Medicare hospitals, more than half of responding hospitals reported

On May 9, 2014, CMS announced it is implementing the first phase of its reforms to the Quality Improvement Organization (QIO) Program in an effort to “gain efficiencies, to eliminate any perceived conflicts of interest, and to better address the needs of Medicare beneficiaries.” Under this first phase, CMS has named two Beneficiary and Family-Centered

On January 24, 2013, CMS is hosting a Special Open Door Forum on “Future Development of the Quality Improvement Organization (QIO) Program.” The call will address ways that QIOs, in partnership with CMS, can: maximize learning and collaboration in healthcare quality improvement and value with local, state, and regional organizations; demonstrate value to beneficiaries

The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would update Medicare payment and other policies for the hospital outpatient prospective payment system (OPPS) and ambulatory surgical centers (ASCs) for calendar year (CY) 2013. The proposed rule also would update Medicare inpatient rehabilitation facility (IRF) quality reporting program policies and various other Medicare policies. The official version of the rule is scheduled to be published in the Federal Register on July 30, 2012. CMS will accept comments on the rule until September 4, 2012. Key provisions of the proposed rule include the following:Continue Reading CMS Issues Proposed OPPS, ASC Policies for 2013

CMS published a rule on February 2, 2011 that would require certain Medicare-certified providers and suppliers to inform their Medicare beneficiaries about their right to file written quality-of-care complaints with the local Quality Improvement Organization (QIO). The new standard would apply to: ambulatory surgical centers (ASCs); hospices; hospitals; long term care (LTC) facilities; home

The GAO has issued a report to Congress highlighting the need for Medicare’s Quality Improvement Organizations (QIO) to provide consistent information to CMS regarding the costs associated with quality of care reviews. The GAO found that because of inconsistencies in QIO reporting, CMS cannot accurately assess the volume of QIOs’ quality of care reviews and the

The GAO has issued a report entitled “Quality Improvement Organizations’ Final Responses to Beneficiary Complaints.” By way of background, QIOs must review written quality-of-care complaints from Medicare beneficiaries and send to the beneficiary a final response summarizing their review findings. A practitioner involved in a case can decline to give consent for the