Questions for October 30th: Special Open Door Forum:
Quality Improvement Organization Beneficiary Protection Program
In preparation for the October 30th Special ODF: Quality Improvement Organization Beneficiary Protection Program, below are the four topics, explained in more detail, that CMS is asking for your feedback. Please keep your responses under two minutes for each question.
We look forward to your participation.
1. Beneficiary Complaint Reviews
In accordance with §1154(a)(14) of the Social Security Act, QIOs are responsible for conducting reviews of written complaints filed by beneficiaries about the quality of services not meeting professionally recognized standards of health care. This responsibility has not been previously detailed in regulation. Please provide feedback regarding specific requirements you believe should be added to the QIO program regulations regarding beneficiary complaint reviews.
2. Quality of Care Reviews
In accordance with §1154(a)(1)(B), QIOs conduct quality of care reviews to determine whether services meet professionally recognized standards of health care. Provisions are included in current regulations detailing the process QIOs must follow in completing these reviews, and currently reviews are based solely on the medical record. Additionally, these regulations have not been updated in decades and CMS is evaluating opportunities to modify current process requirements and improve the effectiveness of the QIO program through these reviews. Please provide feedback regarding changes that could be made to the regulations related to quality of care reviews that could improve the effectiveness of these reviews.
3. Transparency
In accordance with §1154(a)(14), QIOs must inform beneficiaries of the final disposition of complaints. At a minimum, QIOs must advise beneficiaries whether care did or did not meet professionally recognized standard(s) of care, and CMS is evaluating ways to increase the amount of information conveyed to beneficiaries as a result of beneficiary complaint. Please provide feedback regarding the types of information that should be provided to beneficiaries in the final disposition of complaints in addition to whether care did or did not meet professionally recognized standards of care. Also provide feedback on ideas for ensuring we are capturing the totality of quality of care complaints from Medicare beneficiaries.
4. Process Requirements for QIO BPP functions
42 CFR Parts 475, 476, 478, and 480 detail various functions performed by QIOs. In addition to issues surrounding beneficiary complaint reviews, quality of care reviews, and transparency, are there ways to rearrange or change the regulations that will make them more user-friendly and readable and facilitate stakeholders' understanding of the QIOs' responsibilities and the effectiveness of QIOs in improving the quality of health care.
