Winds of Change for Quality Improvement Organizations (QIOs)

on Tuesday, 27 May 2014. All News Items | Case Management | Quality | Coding

What were you doing in 1984? In 1984, Arnold warned us that “I’ll be back” in the Terminator, Harrison Ford saved the children in “Indiana Jones and the Temple of Doom,” and “Ghostbusters” were the ones to call as the year’s top grossing film. This was also the year that QIO’s first answered their call and took on the challenge of helping improve healthcare delivery, safety, and efficiency in all 50 states, DC, Puerto Rico and the Virgin Islands.

There has been tremendous change in healthcare since 1984. QIO’s are not immune to this change and as of August of this year, their 11th Scope of Work (SOW) will bring significant changes to how they operate.

QIO Program Changes with the 11th SOW:

In a May 9th Press Release CMS announced the first step in restructuring the QIO Program to further the aims of improving patient care, health outcomes and saving taxpayer resources.  

The Thursday, May 15, 2014 MLN Connects Weekly Provider eNewsnoted that updates to the program “will allow for greater efficiencies across the program, eliminate any perceived conflicts of interest, and will continue to emphasize the need for greater patient-centered care in support of the needs of Medicare beneficiaries. The QIO program changes include:

  • Separation of 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.”

Phase One: Beneficiary and Family Centered Care (BFCC) QIOs

With this first phase CMS announced that there will be two BFCC QIOs that “will be responsible for ensuring the consistency in the review process with consideration of local factors important to beneficiaries.” Per CMS, this restructuring “highlights CMS’ efforts to restructure the QIO Program to gain efficiencies, to eliminate any perceived conflicts of interest, and to better address the needs of Medicare beneficiaries using BFCC QIOs to focus on providing patients a voice through conducting quality of care reviews, discharge and termination of service appeals, and other areas of required review in various provider settings.”

Type of Case Reviews to be performed by the BFCC QIOs includes:

  • Complaint Reviews
  • Quality of Care Reviews
  • Discharge Appeals
  • Higher Weighted Diagnostic Related Groups (DRG) requests
  • Emergency Medical Treatment and Active Labor Act (EMTALA) reviews.


BFCC QIO Coverage Areas:

CMS awarded the two BFCC QIO contracts to Livanta, LLC located in Annapolis Junction, Maryland and KePRO located in Seven Hills Ohio. The 50 states, DC, Puerto Rico and the Virgin Islands have been divided into Five (5) Areas.

Livanta, LLC was awarded Areas 1 and 5 and 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, Virgin Islands

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

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

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

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

Phase Two: Quality Innovation Network (QIN) QIOs

CMS expects that the second phase will be in July of this year when they will “award contracts to organizations that will directly work with providers and communities on data-driven quality initiatives to improve patient safety, reduce harm, and improve clinical care and transparency at local, regional, and national levels through Quality Innovation Network and Value, Incentive and Quality Reporting support contractors.”

What you need to know:

  • It will be important to identify who your BFCC QIO is in order to know:
    • What BFCC QIO contact information you will need to put on the Important Message from Medicare that is provided to Medicare Beneficiaries that have been admitted as an Inpatient to your facility.
    • Identify who will be reviewing your records when the decision has been made to re-bill a claim to a Higher Weighted DRG.
  • CMS plans to provide an Open Door Forum to discuss the changes and the impact it will have on the provider community in the near future.

Link to Press Release:

Link to CMS QIO webpage:

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc. Beth has over twenty-three years of experience in healthcare including eleven years in Case Management at a large multi-facility health system. In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare. You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information. MMP, Inc. is not offering legal advice. Every reasonable effort has been taken to ensure the information is accurate and useful.

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