Quality Improvement Organizations

STATUS UPDATE: AWARD OF QIO FOR STATE OF MAINE (9-29-11)

On August 5, 2011, CMS announced publicly it has awarded the contract for the QIO Program 10th Statement of Work (beginning August 1) to the Northeast Health Care Quality Foundation for the state of Maine.  On September 7, 2011, a protest against this award was filed with the Government Accountability Office (GAO). GAO's decision on the protest must be issued no later than 100 days after the protest was filed. In this case, the deadline for the GAO decision on the protest is December 15, 2011.  In accordance with the Competition in Contracting Act (CICA), the filing of the protest triggered an automatic stay on performance of the Northeast Health Care Quality Foundation contract pending GAO's decision.  This stay on performance will not impact the rights of Maine-based beneficiaries to file appeals of discharges from different provider settings or to file complaints about the quality of care in their state. 

What are QIOs?

CMS contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as that state/jurisdiction's Quality Improvement Organization (QIO) contractor. QIOs are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care and to implement improvements in the quality of care available throughout the spectrum of care. QIO contracts are 3 years in length, with each 3-year cycle referenced as an ordinal “SOW.”

What do QIOs do?

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' 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. 

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. CMS views the QIO Program as an important resource in its 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 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.