Industry Insights

CMS Restructures QIO Program

July 2014
Author:  Suzy Harvey

Suzy Harvey

Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
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Most skilled nursing facilities (SNFs) are aware their state Quality Improvement Organization (QIO) is changing. But why?

In an effort to remove the appearance of conflict of interest, the Centers for Medicare & Medicaid Services (CMS) have separated medical review from quality improvement activities to create three separate entities. QIOs have long had a dual mission, holding providers accountable to beneficiaries while supporting providers on quality improvement initiatives.

There now will be three separate programs:

  • Medical case review to be performed by Beneficiary and Family-Centered Care QIOs (BFCC-QIOs)
  • Quality improvement and technical assistance QIOs to be performed by Quality Innovation Network QIOs (QIN-QIOs)
  • Value, Incentives and Quality Reporting Centers (VIQRC) will initially work with hospitals

CMS announced the first phase of the QIO restructuring on May 9, 2014, and the second phase was announced on July 18, 2014. CMS plans to introduce program changes that will take effect with the beginning of its five-year 11th Statement of Work—the QIO contracts cycle—on August 1, 2014.

The first phase of the restructuring will reduce the current number of QIOs from 53 to just two nationwide. The two BFCC-QIO contracts were awarded to Livanta, LLC, in Annapolis Junction, Maryland, and KePRO in Seven Hills, Ohio. The BFCC-QIOs will focus on providing a voice for patients by conducting quality of care reviews, discharge and termination-of-service appeals, investigating beneficiary complaints—including discrimination referrals—and performing medical necessity reviews. The BFCC-QIOs will make recommendations for quality improvement initiatives to the QIN-QIOs. The BFCC-QIOs were awarded specific geographical regions:

  • Livanta was awarded Areas 1 and 5
  • KePRO was awarded Areas 2, 3 and 4

Area 1:  Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Puerto Rico, Rhode Island, Vermont and Virgin Islands

Area 2:  Delaware, District of Columbia, Florida, Georgia, Maryland, North Carolina, South Carolina, Virginia and West Virginia

Area 3:  Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, New Mexico, North Dakota, Oklahoma, South Dakota, Tennessee, Texas, Utah and Wyoming

Area 4:  Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio and Wisconsin

Area 5:  Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon and Washington

Beginning August 1, 2014, providers and Medicare beneficiaries must contact Livanta and KePRO for all appeal requests and quality of care concerns. Staff will be available 9 a.m. - 5 p.m. Monday through Friday and 11 a.m. -
3 p.m. on weekends and holidays. 

SNF providers should take the following steps during the transition:

  • Update all copies of the Notice of Medicare Non-Coverage (CMS Form 10123) to include the proper BFCC-QIO name and phone number
  • Replace all print and electronic copies of beneficiary resources that include the former QIO contact information
  • Update policies and procedures that reference the former QIO

Below is the important BFCC-QIO contact information:

The second phase of the restructuring will create a new approach to improve care for beneficiaries, families and caregivers. New QIN-QIO contracts were awarded to 14 organizations. Each of the 14 QIN-QIOs will work on specific initiatives, such as reducing health care-associated infections, reducing readmissions, reducing pressure ulcers and medication errors. The QIN-QIOs will work with nursing homes to improve resident care, provide support in using interoperable health information technology to improve coordination of care, promote preventive activities in reducing cardiac disease and diabetes, reduce health care disparities and improve patient and family engagement. QIN-QIO projects will be championed at the local level and clinical practice QIN-QIOs will provide assistance for improvement in CMS value-based purchasing programs. Many QIN-QIOs will subcontract with the former state QIOs to continue working to improve the quality of health care at the local level.

Below are the QIN-QIO awarded contracts:

The awards for Indiana, Puerto Rico and Virgin Islands have not yet been determined.

If you have additional questions about how these changes could affect your organization, contact your BKD advisor.

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