QIOs Deserve Another Look
Who is Your Medicare Quality Improvement Organization?
By Dorothy Steed, CPC-H, CHCC, CPUM, CPUR, ACS-OP, RCC, CCS-P, E/M, RMC, CPAR
Peer Review Organizations (PRO), also known as The Medicare Quality Improvement Organization (QIO), are contracted entities by the Centers of Medicare and Medicaid Services (CMS) to provide quality improvement. Their focus is on physician offices, hospitals, nursing homes, Medicare beneficiaries and Medicaid. Usually staffed by a medical director and nurses, they may also contract with specialty physicians and with credentialed coders to review clinical and coding selections.
QIOs serve as an information resource and work with physician practices to improve care. There may be focused initiatives, such as diabetes, and they may reduce the occurrence or severity of recognized manifestations by using clinical guidelines for early detection and effective management. They may also provide educational information regarding cultural and language-appropriate standards.
Through the U. S. Department of Health and Human Services (HHS), CMS provides public reports on quality measures for every nursing home certified by Medicare and Medicaid. These measures are posted on Medicare’s website (www.medicare.gov) on the Nursing Home Compare page (on the home page, click on “Compare Nursing Homes in Your Area” under Search Tools). Each state’s QIO provides assistance to consumers in using the measures for making nursing home assessments. Providers may be assisted in improving care that relates to these measures.
The QIO provide utilization and quality management services on a consultation basis for state Medicaid programs. Examples of this service may include reviews for durable medical equipment (DME), vision and dental care, oral and maxillofacial surgery, precertification for both inpatient admissions and outpatient procedures, psychiatric and psychological services, radiology procedures, swingbed reviews, and medication administration. The QIO may provide oversight functions of state programs, and conduct medical reviews of problem claims and unusual billing patterns.
In 2003, CMS and the HHS rolled out the Home Health Quality Initiative (HHQI). The effort of the HHQI is to improve the quality of care in Medicare-certified home health services by using quality performance measures.. Check for these measures under Home Health Compare (on the Medicare website).
CMS ensures that Medicare hospitals are in compliance with federal mandated standards for patient quality of care, health, and safety. They issue standards for safe operation, develop guidelines and procedures, provide training for conducting surveys and coordinate these surveys of individual states. Surveys may be conducted to investigate complaints of non-compliance as needed. The QIO may oversee hospital Appropriate Care Measures ACM for quality improvement in certain clinical topics and appropriate care. The Hospital Payment Monitoring Program in inpatient facilities is intended to prevent reimbursement errors through analyzing data, conducting focused audits, and creating system changes to ensure that payments are accurate for services that are reasonable, appropriate, and medically necessary Through Medicare’s artificial intelligence claims tracking system, unusual data reporting by a facility may be identified and tracked, triggering the fiscal intermediary to target that claim for review.
Medicare beneficiaries concerned about the quality of care received through a hospital, skilled nursing facility, home care agency or hospice may request a review of those complaints by the QIO. These four services are covered under the Part A Medicare Program.
The Patient Bill of Rights they receive includes the following:
- The Right to Information. Patients have the right to receive accurate, easily understood information to assist in making informed decision about their care and coverage.
- The Right to Choose. Patients have the right to choices about healthcare providers.
- Access to Emergency Services. Patients have the right to emergency health services when and where the need arises.
- Being a Full Partner in Health Care Decisions. Patients have the right to fully participate in all decisions related to their health care.
- Care Without Discrimination. Patients have the right to considerate, respectful care from all health care providers at all times and under all circumstances.
- The Right to Privacy. Patients have the right to communicate with their healthcare providers in confidence and have the confidentiality of individually identifiable health care information protected.
- The Right to Speedy Complaint Resolution. Patients have the right to an efficient and fair process for resolving differences with their health plans, healthcare providers and institutions that serve them.
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