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Quality Improvement Organizations

What are QIOs?

A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. QIOs work under the direction of the Centers for Medicare & Medicaid Services to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries and the Medicare Trust Fund.

What do QIOs do?

The QIO Program, one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries, is an integral part of the U.S. Department of Health and Human (HHS) Services' National Quality Strategy for providing better care and better health at lower cost. By law, the mission of the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries. Based on this statutory charge, and CMS's program experience, CMS identifies the core functions of the QIO Program as:

  • Improving quality of care for beneficiaries;
  • Protecting the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting; and
  • Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law.

What are Beneficiary and Family Centered Care (BFCC)-QIOs?

BFCC-QIOs improve healthcare services and protect beneficiaries through expeditious statutory review functions, including complaints and quality of care reviews for people with Medicare. The BFCC-QIO ensures consistency in the case review process while taking into consideration local factors and local needs for general quality of care, medical necessity, and readmissions.

What are Quality Innovation Network (QIN)-QIOs?

QIN-QIOs improve healthcare services through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families and convening community partners for communication and collaboration. QIN-QIOs also work to improve the quality of healthcare for targeted health conditions and priority populations and to reduce the incidence of healthcare-acquired conditions to meet national and local priorities.

Why does CMS have QIOs?

CMS relies on QIOs to improve the quality of health care for all Medicare beneficiaries. Furthermore, QIOs are required under Sections 1152-1154 of the Social Security Act. The QIO Program is an important resource in CMS’s effort to improve quality and efficiency of care for Medicare beneficiaries. Throughout its history, the Program has been instrumental in advancing national efforts to motivate providers in improving quality, and in measuring and improving outcomes of quality.

QIO Program Transformation

CMS redesigned its QIO Program to further enhance the quality of services for Medicare beneficiaries. The new program structure maximizes learning and collaboration in improving care, enhances flexibility, supports the spread of effective new practices and models of care, helps achieve the priorities of the National Quality Strategy and the goals of the CMS Quality Strategy, and delivers program value to beneficiaries, patients, and taxpayers. 

The QIO Program changes include separating case review from quality improvement, extending the contract period of performance from three (3) to five (5) years, removing requirements to restrict QIO activity to a single entity in each state/ territory, and opening contractor consideration to a broad range of entities to perform the work. 

Now, one group of QIOs will handle complaints while another group will provide technical assistance to support providers and suppliers. QIOs will have new skills for transforming practices, employing lean methodologies, assisting with value based purchasing programs and developing innovative approaches to quality improvement.

QIO Reports to Congress

CMS is required to publish a Report to Congress every fiscal year that outlines the administration, cost, and impact of the QIO Program.  See the links in the "Downloads" section to read our most recent fiscal year Report to Congress.

Also in the "Downloads" section, read our special Report to Congress in response to the Institute of Medicine's 2006 study on the QIO Program, Medicare's Quality Improvement Organization Program: Maximizing Potential.  CMS' response to that report outlines improvements, based on an extensive CMS review and recommendations from the Institute of Medicine, to strengthen Medicare's oversight and evaluation of the QIO Program to better meet the future needs of beneficiaries and health care providers.