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What are Medicare Quality Improvement Organizations?

October 6, 2016

The Quality Improvement Organization (QIO) Program is central to Medicare’s efforts to improve the quality of care and medical outcomes for Medicare beneficiaries. There are two QIOs in each state as well as the District of Columbia, the U.S. Virgin Islands, and Puerto Rico:

  1. Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) manage all beneficiary complaints and quality of care reviews to ensure consistency in the review process while taking into consideration local factors important to beneficiaries and their families.
  2. Quality Innovation Network – Quality Improvement Organizations (QIN-QIOs) are responsible for working with providers and communities on QIO Program quality initiatives to improve patient safety and clinical care to Medicare beneficiaries and to minimize health-care waste and abuse at local, regional, and national levels.

Established by the Social Security Act, quality improvement organizations are contracted with the Centers for Medicare & Medicaid Services (CMS), the federal agency that administers the Medicare program. Quality improvement organizations (QIOs) are private, non-profit groups. Each organization is made up of practicing doctors and other health care professionals who use their medical expertise to conduct case reviews during the appeals process and to evaluate the appropriateness and effectiveness of health services for Medicare beneficiaries. All QIOs are independent entities, and each one must have at least one health provider representative and one consumer representative on its governing board. To qualify as a QIO, the group cannot be a health-care facility (such as a hospital or clinic) or affiliated with one.

Beneficiary and Family Centered quality improvement organizations and the Medicare appeals process

Beneficiary and Family Centered quality improvement organizations are involved in the Medicare appeals process. For example, if you believe you were discharged from a hospital too soon, you have a right to file an appeal to receive continued Medicare coverage. The QIO works with the hospital or health provider to determine if it is medically necessary for you to receive further inpatient hospital services and whether Medicare will cover that care.

Quality improvement organizations can also help with general complaints and questions you may have regarding the quality of care you are receiving or received recently. This includes complaints regarding the safety or appropriateness of care, hospital conditions, or the competence of a particular health professional providing care to you. It may also include concerns about whether a prescribed medication or treatment was medically necessary or appropriate for your condition.

If you are unhappy with the quality of care or services you received from a Medicare-participating doctor, health professional, hospital or other health-care facility, you can contact a QIO to file a complaint. To find the quality improvement organization in your state, visit Medicare.gov. You can also contact Medicare for more information at 1-800-MEDICARE (1-800-633-4227) (TTY users 1-877-486-2048). Medicare representatives are available 24 hours a day, seven days a week.

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