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Under the direction of CMS, the Quality Improvement Organization (QIO) Program consists of a national network of 53 QIOs, responsible for each U.S. state, territory, and the District of Columbia. QIOs work with consumers and physicians, hospitals, and other caregivers to refine care delivery systems to make sure patients get the right care at the right time, particularly patients from underserved populations. The Program also safeguards the integrity of the Medicare Trust Fund by ensuring that payment is made only for medically necessary services, and investigates beneficiary complaints about quality of care. Quality Improvement Work To achieve the vision of the QIO Program, the right care for every person every time, the Program assists providers in transforming quality to make healthcare: - Safe
- Effective
- Patient-Centered
- Timely
- Efficient
- Equitable
Through QIOs and End-Stage Renal Disease (ESRD) Networks, and in partnership with other stakeholders, the Program assists providers in transforming healthcare quality, and protects beneficiaries and the Trust Fund, using the following strategies: - Measure and report performance
- Adopt healthcare information technology and use it effectively
- Redesign process
- Transform organizational culture
Beneficiary Protection CMS contracts with the QIOs to conduct case review to ensure that care provided to Medicare beneficiaries meets professionally recognized standards of healthcare and that Medicare pays only for services that are reasonable and necessary. The Beneficiary Complaint Response Program has a systematic approach to identifying quality concerns. The emphasis of the Beneficiary Complaint Response Program is on ways to work with the physicians and practitioners in the community so together we can improve the quality of care for the Medicare beneficiaries. QIOs are required to conduct individual case review in the following categories: - Potential antidumping violations
- Assistants at cataract surgery
- Beneficiary complaints, notices, and appeals
- Hospital and Managed Care Plan notices of non-coverage
- Potential concerns identified during project data collection
- Hospital-requested higher-weighted diagnosis related group (DRG) adjustments
The Report to Congress in the Downloads area outlines improvements, based on an extensive CMS review and IOM recommendations, to strengthen Medicare's oversight and evaluation of the Medicare Quality Improvement Organization Program to better meet the future needs of beneficiaries and health care providers.
Page Last Modified: 01/18/2008 11:13:01 AM
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