Organizations that are designated as QIO-like entities can perform two different, but similar, activities addressed in two separate sections of Federal Medicaid law. 

First, section 1902 (a)(30)(A) of the Social Security Act (the Act) requires that State Medicaid Agencies provide methods and procedures to safeguard against unnecessary utilization of care and services and to assure "efficiency, economy and quality of care." Under section 1902 (d), a State can contract with a QIO or QIO-like entity to perform medical and utilization review functions required by law.  The contracts must be consistent with the QIO legislation.  Section 1903 (a)(3)(C) of the Act specifies that 75% Federal Financial Participation is available for State expenditures for the performance of medical and utilization reviews or external quality reviews by a QIO, or by entity, which meets the requirements of section 1152 of the Act (i.e., "QIO-like entity").

Second, section 1902 (a)(30)(C) of the Act requires the performance of an annual, independent, external review of the quality of services furnished under each State contract with a Managed Care Organization (MCO) that is governed by section 1903 (m) of the Act.  Section 1902 (a)(30)(C) further specifies that only three types of organizations are permitted to perform this review: 1) a QIO that has a contract with the Secretary to perform Medicare reviews; 2) an organization which is determined by the Secretary to meet the requirements for qualifying as a QIO contained in section 1152 of the Act (i.e.; a QIO-like entity); and 3) a private accreditation body.

NOTE: The Balanced Budget Act of 1997 created section 1932 (c)(2) of the Act, which would replace section 1902 (a)(30)(C) with a new requirement for annual, external quality review (EQR) of Medicaid MCOs.  In this new requirement, States are no longer restricted to using QIO, QIO-like and accrediting organizations to perform EQR; States may contract with "qualified, independent" entities.  CMS has specified requirements for qualifications and independence in a Notice of Proposed Rulemaking, published on December 1, 1999.  When this rule becomes final, the QIO-like designation will no longer have any applicability to statutory requirements for this annual, independent, external review of Medicaid MCO quality.

Review of Applications

The Office of Clinical Standards and Quality (OCSQ) within the CMC, reviews applications from prospective QIO-like organizations to determine whether the organization meets the requirements in section 1152 of the Act and 42 CFR Part 475 as specified below:

• Organization must be physician-sponsored or physician-access;
• Organization must be able to perform review functions specified under section 1154 of the Act related to the performance of medical necessity and quality of care review.  QIO-like entities must be able to review cases and analyze patterns of care related to medical necessity and quality review. (We do not determine if the organization meets the states' requirements for external quality review specified in sections 1902 (a)(30)(A), 1902 (a)(30)(C) and 1932 (c)(2) of the Act, nor have we evaluated the organization to perform the same functions as a QIO under contract with CMS);
• Must have at least one individual who is representative of consumers on its' governing body; and
• Must not be a health care facility, health care facility affiliate or health care association.

It should be noted that the States have additional requirements for organizations with which they contract, particularly relating to external quality review as specified in sections 1902 (a)(30)(A), 1902 (a)(30)(C) and 1932 (c)(2) of the Act.  QIO-like entity status creates eligibility for organizations seeking such contracts.  States evaluate whether eligible organizations meet their additional requirements.

In order for OCSQ to make a determination as to whether your organization qualifies as a QIO-like entity, you must demonstrate to us that you meet the above requirements and provide information that describes your ability to review cases and analyze patterns of care related to medical necessity and quality of care.

Three-Year Certification

If your organization is approved as a QIO-like entity, QIO-like certification will be limited for a period of three years.  You will be required to provide an annual assurance statement of your continued adherence to certification requirements within 30 days of the last month of the first certification year and within 30 days of the last month of the second certification year.  In addition, you must notify this Office if there are changes in the name and address of the organization, pool of physician reviewers, etc., for a reevaluation of your certification.

Submit your application to the following address:

Centers for Medicare and Medicaid Services
Attn: Director of Quality Improvement Group
Office of Clinical Standards and Quality
7500 Security Boulevard
Mail Stop S3-02-01
Baltimore, Maryland 21244-1850

Physician-Sponsored Organization

To be eligible as a physician-sponsored organization, you must demonstrate to CMS that your organization meets the following requirements:

• Is composed (have physicians as owners or members) of at least 20% of the licensed doctors of medicine and osteopathy practicing medicine or surgery in the State; (i.e., at least 20 percent of the practicing physicians in the State are owners of the QIO, or the QIO is owned by an entity which includes at least 20% of the practicing physicians in the State as members; or
• Is composed (have physicians as owners or members) of at least 10% of the licensed doctors of medicine and osteopathy practicing medicine or surgery in the State, and demonstrate through means (e.g., letters of support from physicians and physician organizations) acceptable to CMS that the organization is representative of an additional 10% of the practicing physicians in the State
• Is not a healthcare facility, healthcare facility association, or healthcare facility affiliate; and
• It must have at least one individual who is representative of consumers on its governing body.

Physician-Access Organization

To be eligible as a physician-access organization, you must demonstrate to CMS that your organization meets the following requirements:

• Has arrangements with doctors of medicine or osteopathy, licensed in the State to conduct review for your organization;
• Has available at least one physician, licensed in the State from every generally recognized specialty (i.e., CMS has defined generally recognized specialties as follows: Cardiology, Gerontology, Gynecology, Immunology/Rheumatology/Endocrinology, Internal Medicine/Family Practice, Neurology, Oncology, Ophthalmology, Orthopedics/Podiatry, Psychiatry, Pulmonary Medicine, Radiology, Surgery (includes subspecialties), and Urology/Nephrology) who is in active practice in your review area ( the pool of licensed physician reviewers must be practicing in the State where certification is requested);
• Is not health care facility, health care facility association, or health care facility affiliate; and
• It must have at least one individual who is representative of consumers on its governing body.

Ability To Perform Review Functions

In order to demonstrate that your organization has the ability to perform review activities set forth in Section 1154 of the Act, you must document and submit for CMS review and approval a brief explanation of your capability to perform the work by demonstrating past/current experience in this area, or absent this, offer a detailed plan as to how you would perform these activities.  You must meet all the requirements listed below and provide a copy of your policy and procedures, with appropriate sections highlighted documenting:

• Medical record and review information must be maintained confidentially.
• Appropriate information must be collected in review of a case.
• Denial decisions must be made by a physician.
• Review decisions are made on the basis of written criteria.
• Review criteria can be provided to practitioners and providers when appropriate, and a process exists for modifying them in response to practitioner recommendations.
• Complaint and appeal process must include procedures for receiving and responding to complaints and appeals.

Provide a copy of your organizational chart and listing of staff documenting:

• Physicians must be involved in the management of the program.
• Clinical staff must collect clinical information.

Provide evidence of your ability to analyze patterns of medical review information for purposes of reporting and conduct of subsequent reviews.

Provide evidence of your past and current experience in medical and quality review.

Definitions

A health care facility is defined as an entity that directly provides or supplies health care services for which payment may be made in whole or in part under Title XVIII of the Act.  A "health care facility affiliate" is an organization which has a board on which more than 20 percent of the members are affiliated through management, ownership or common control with one or more facilities.

Consumer Representative is defined as a Medicare beneficiary (fee for service or managed care). The consumer representative must not be a practicing physician, or a governing board member, office, partner, owner of more than 5 percent interest in a health care facility, or managing employee of a health care facility or association of health care facilities.

Statement of Work

The current contract requirements for QIOs can be found in the Statement of Work (SOW).  The SOW outlines the work of the QIOs over a three-year contract cycle.

Downloads
There are no Downloads
Related Links Inside CMS
There are no Internal Links
Related Links Outside CMS
MedQIC QIO Directory AHQA

Page Last Modified: 12/14/2005 12:00:00 AM
Help with File Formats and Plug-Ins