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Overview

On August 8, 2008, CMS publicly announced the award of 53 contracts for the QIO Program 9th Statement of Work (SOW) with an effective date of August 1, 2008.  Of the 53 contracts for the core 9th SOW, 13 were competitively awarded and 40 were negotiated renewals.  On August 12 and 13, 2008 respectively, CMS received notification that a protest to the award of WVMI Quality Insights for the state of North Carolina  and a protest to the award of Health Services Advisory Group (HSAG) for the state of California had been filed with the Government Accountability Office (GAO).  As both protests were filed timely, an automatic stay of performance went into effect for both the NC and CA 9th SOW awards.  The following provides an update to the status of the protests and the stay of performance for the states of NC and CA.

**UPDATE: November 21, 2008**

Status of QIO Contract for North Carolina

 

CMS is currently making a new award decision for this contract. At this time, the original awardee, West Virginia Medical Institute is under a stop work order and there is a protest filed with the Government Accountability Office on this procurement. Until further notice, North Carolina beneficiaries who wish to file complaints or appeals about the quality of their care under Medicare should contact the existing QIO in North Carolina, the Carolina Center for Medical Excellence at 1-800-922-3089.

Status of QIO Contract for California

The Court of Federal Claims found in CMS' favor, denying the bid protest filed.  CMS is able to continue transitioning work to the new California QIO for the 9th SOW, HSAG.

At this time HSAG has assumed beneficiary protection responsibilities in California, and is the only entity serving as the California QIO.  California beneficiaries who wish to file complaints or appeals about the quality of their care under Medicare should contact the HSAG at 1-800-841-1602 (or 1-800-881-5980 for TDD-hearing impaired callers).

**UPDATE: AUGUST 5, 2008**

In August 2008, QIOs began work on their 9th Statement of Work with CMS. To learn more, read our Fact Sheet on the 9th SOW page.

CMS contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction's Quality Improvement Organization (QIO) contractor. QIOs are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care. QIO contracts are 3 years in length, with each 3-year cycle referenced as an ordinal "SOW."

What do QIOs do?

By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS' Program experience, CMS identifies the core functions of the QIO Program as:

  • Improving quality of care for beneficiaries;
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
  • Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law. 

Why does CMS have QIOs?

CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. Furthermore, QIOs are required under Sections 1152-1154 of the Social Security Act. CMS views the QIO Program as an important resource in its effort to improve quality and efficiency of care for Medicare beneficiaries. Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.

The Report to Congress in the Downloads area outlines improvements, based on an extensive CMS review and recommendations from the Institute of Medicine, to strengthen Medicare's oversight and evaluation of the QIO Program to better meet the future needs of beneficiaries and health care providers.

Downloads

Report to Congress: Response to IOM Study on the QIO Program [PDF, 225KB]
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Page Last Modified: 11/21/2008 2:56:34 PM
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