Quality Improvement Organizations (QIOs) work under contract to Medicare. The Centers for Medicare & Medicaid Services (CMS) reviews contracts once every three years to ensure that QIOs are doing their jobs effectively. CMS selects QIOs based on whether a group has the proper resources available to ensure proper peer review. In order to be eligible to become a QIO, an organization must submit a proposal to CMS, and then prove through written certifications and documentation that it meets the requirements of either physician access or physician sponsorship.
The CMS defines a group as physician-sponsored if at least 20 percent of its members or owners are either licensed doctors of medicine or osteopathy practicing in the QIO service area (the state the QIO serves). An organization can also qualify as physician-sponsored if at least 10 percent of its members are licensed doctors practicing in the area and that it represents another 10 percent of physicians in the state. A physician-sponsored group can NOT be a health care facility (a facility that directly provides health care services to Medicare patients), a health care affiliate or a health care association.
Physician-access groups can also become QIOs. CMS considers an organization a physician-access group if it has made arrangements with licensed doctors practicing in the state to can conduct peer reviews. The group must also have a least one doctor licensed and practicing in the state for each generally recognized specialty and subspecialty. Like physician-sponsored organizations, physicians-access groups cannot be health care facilities, affiliates or associations. To qualify for service as a QIO, an organization must also have at least one person who represents consumers on its governing board.
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