BusinessPolicy & Law

What are QIOs?

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According to the CMS website, Quality Improvement Organizations (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. 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 QIO contractor. QIO’s core functions include:

  • Improving quality of care for beneficiaries;
  • Ensuring that Medicare pays only for reasonable and necessary services and goods in the most appropriate setting; and
  • Addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA) [EMTALA require hospitals and ambulance services to provide care to anyone needing emergency services.]
  • On February 2, 2011, CMS published a proposed rule that would require most Medicare-participating providers and suppliers to give Medicare beneficiaries written notice about their right to contact a Medicare Quality Improvement Organization (QIO) with concerns about the quality of care they receive under the Medicare program.

Examples of work the QIOs perform includes:

  • The Federal Doctor’s Office Quality Information Technology initiative (DOQ-IT). This initative promotes the adoption of electronic health record systems and information technology in small-to-medium sized physician offices with a vision of enhancing access to patient information, decision support, and reference data, as well as improving patient-clinician communications.
  • Surgical Care Improvement Project (SCIP). This hospital based quality improvement initiative led by CMS that focuses on reducing the rate of adverse outcomes of common surgical procedures..

History According to Zeitler (2004), Peer Review Organizations (PROs)) were established through the Peer Review Improvement Act of 1982 (a part of the Tax Equity and Fiscal Responsibility Act of 1982), replacing Professional Standards Review Organizations (PSROs) that had been established in 1972. In FY2002, they were renamed Quality Improvement Organizations (QIOs).

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