[Federal Register Volume 75, Number 227 (Friday, November 26, 2010)]
[Notices]
[Pages 72830-72831]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2010-28817]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3229-N]


Medicare Program; Quality Improvement Organization (QIO) 
Contracts: Solicitation of Proposals From In-State QIOs--Idaho, Maine, 
South Carolina, and Vermont

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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SUMMARY: This notice fulfills the Secretary's obligation under section 
1153(i) of the Social Security Act (the Act) to provide at least 6 
months' advance notice of the expiration dates of contracts with out-
of-State Quality Improvement Organizations (QIOs) before renewing any 
of those QIOs' contracts. It also specifies the period of time in which 
in-State QIOs may submit a proposal for those contracts.

DATES: Interested organizations may submit a proposal to perform the 
QIO work in any of the States listed in this announcement. The request 
for proposal (RFP) will be made available to all interested 
organizations through the Federal Business Opportunities (http://www.fedbizopps.gov) Web site. CMS anticipates that the RFP for the QIO 
contracts will be released sometime during the month of February 2011. 
Interested organizations should monitor the Federal Business 
Opportunities Web site for all information relating to the RFP.

ADDRESSES: Proposals for the contracts must be submitted to the Centers 
for Medicare & Medicaid Services, Acquisitions and Grants Groups, OAGM, 
Attn.: Naomi Haney-Ceresa, 7500 Security Boulevard, Mail Stop C2-21-15, 
Baltimore, Maryland 21244-1850.

FOR FURTHER INFORMATION CONTACT: Alfreda Staton, (410) 786-4194.

SUPPLEMENTARY INFORMATION:

I. Background

    The Peer Review Improvement Act of 1982 (title I, subtitle C of the 
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Pub. L. 97-
248) amended Part B of title XI of the Act (the Act) by establishing 
the Utilization and Quality Control Peer Review Organization program.
    Utilization and Quality Control Peer Review Organizations, now 
known as Quality Improvement Organizations (QIOs), currently review 
certain health care services furnished under title XVIII of the Social 
Security Act (the Act) (Medicare) to determine whether those services 
are reasonable, medically necessary, provided in the appropriate 
setting, and are of a quality that meets professionally recognized 
standards. QIO activities are a part of the Health Care Quality 
Improvement Program (HCQIP), a program that supports our mission to 
ensure health care quality for our beneficiaries. The HCQIP rests on 
the belief that a plan's, provider's, or practitioner's own internal 
quality management system is key to good performance. The HCQIP is 
carried out locally by the QIO in each State. Under the HCQIP, QIOs 
provide critical tools (for example, quality indicators and 
information) for plans, providers, and practitioners to improve the 
quality of care provided to Medicare beneficiaries. The Congress 
created the QIO program in part to redirect, simplify, and enhance the 
cost-effectiveness and efficiency of the peer review process.
    In June 1984, we began awarding contracts to QIOs. We currently 
maintain 53 QIO contracts with organizations that provide medical 
review activities for the 50 States, the District of Columbia, Puerto 
Rico, and the Virgin Islands. The organizations that are eligible to 
contract as QIOs have satisfactorily demonstrated that they are either 
physician-sponsored or physician-access organizations in accordance 
with section 1152 of the Act and our regulations at 42 CFR 475.102 and 
475.103. A physician-sponsored organization is one that is both 
composed of a substantial number of the licensed doctors of medicine 
and osteopathy practicing medicine or surgery in the respective review 
area and who are representative of the physicians practicing in the 
review area. A physician-access organization is one that has available 
to it, by arrangement or otherwise, the services of a sufficient number 
of licensed doctors of medicine or osteopathy practicing medicine or 
surgery in the review area to ensure adequate peer review of the 
services furnished by the various medical specialties and 
subspecialties. In addition, a QIO cannot be a health care facility, 
health care facility association, a health care facility affiliate, or 
in most cases a payor organization. (The regulations provide that, in 
the event CMS determines no otherwise qualified non-payor organization 
is available to undertake a given QIO contract, CMS may select a payor 
organization which otherwise meets certain requirements to be eligible 
to conduct Utilization and Quality Control Peer Review as specified in 
Part B of Title XI of the Act and its implementing regulations.) 
Section 1152(2) of the Act requires QIOs to perform review functions in 
an

[[Page 72831]]

efficient and effective manner, and perform reviews of quality of care 
in an area of medical practice where actual performance is measured 
against objective criteria, which defines acceptable and adequate 
practice. The selected organization must have a consumer representative 
on its governing board.
    The Omnibus Budget Reconciliation Act of 1987 (Pub. L. 100-203) 
amended section 1153 of the Act by adding paragraph (i). This provision 
prohibits CMS from renewing the contract of any QIO that is not an in-
State QIO without first publishing in the Federal Register a notice 
announcing when the contract will expire. This notice must be published 
no later than 6 months before the date the contract expires and must 
specify the period of time during which an in-State organization may 
submit a proposal for the QIO contract for that State. If one or more 
qualified in-State organizations submit a proposal for the QIO contract 
within the specified period of time, we cannot automatically renew the 
current contract on a noncompetitive basis, but must instead provide 
for competition for the contract in the same manner used for a new 
contract under section 1153(b) of the Act. An in-State QIO is defined 
under section 1153(i)(3) of the Act as a QIO that has its primary place 
of business in the State in which review will be conducted (or, be a 
subsidiary of a parent corporation, whose headquarters is located in 
that State).
    There are currently 4 QIO contracts with entities that do not meet 
the statutory definition of an in-State QIO. The areas affected for 
purposes of this notice along with the respective contract expiration 
dates are as follows:

Vermont--July 31, 2011
Maine--July 31, 2011
Idaho--July 31, 2011
South Carolina--July 31, 2011

II. Provisions of the Notice

    This notice announces the scheduled expiration dates of the current 
contracts between CMS and the out-of-State QIOs responsible for review 
in the areas mentioned above.
    Interested in-State organizations may submit a proposal in 
competing to become the QIO for these States. In order to be eligible 
for contract award, the organization must have its primary place of 
business in the States in which review will be conducted or be a 
subsidiary of a parent corporation, whose headquarters is located in 
that State. In order to be eligible for contract award, each interested 
organization must further demonstrate that it meets the following 
requirements:

A. Be Either a Physician-Sponsored or a Physician-Access Organization

1. Physician-Sponsored Organization
    a. The organization must be composed of a substantial number of the 
licensed doctors of medicine and osteopathy practicing medicine or 
surgery in the review area, who are representative of the physicians 
practicing in the review area.
    b. The organization must not be a health care facility, health care 
facility association, health care facility affiliate, or payor 
organization. However, statutes and regulations provide that, in the 
event CMS determines no otherwise qualified non-payor organization is 
available to undertake a given QIO contract, CMS may select a payor 
organization which otherwise meets requirements to be eligible to 
conduct Utilization and Quality Control Peer Review as specified in 
Part B of Title XI of the Act and its implementing regulations.
    c. In order to meet the ``substantial number of doctors of medicine 
and osteopathy'' requirements as specified above in paragraph A.1.a, an 
organization must state and have documentation in its files showing 
that it is composed of at least 10 percent of the licensed doctors of 
medicine and osteopathy practicing medicine or surgery in the review 
area. In order to meet the representation requirements as specified 
above in paragraph A.1.a, an organization must state and have 
documentation in its files demonstrating that it is composed of at 
least 20 percent of the licensed doctors of medicine and osteopathy 
practicing medicine or surgery in the review area. Alternatively, if 
the organization does not demonstrate that it is composed of at least 
20 percent of the licensed doctors of medicine and osteopathy 
practicing medicine or surgery in the review area, the organization 
must demonstrate in its proposal, through letters of support from 
physicians or physician organizations, or through other means, that it 
is representative of the area physicians.
2. Physician-Access Organization
    a. The organization must have available to it, by arrangement or 
otherwise, the services of a sufficient number of licensed doctors of 
medicine or osteopathy practicing medicine or surgery in the review 
area to ensure adequate peer review of the services furnished by the 
various medical specialties and subspecialties.
    b. The organization must not be a health care facility, health care 
facility association, health care facility affiliate, or payor 
organization.
    c. An organization meets the requirements specified above in 
paragraph A.2.a., if it demonstrates that it has available to it at 
least one physician in every generally recognized specialty and has an 
arrangement or arrangements with physicians under which the physicians 
would conduct review for the organization.

B. Have at Least One Individual Who Is a Representative of Consumers on 
Its Governing Board

    If one or more organizations meet the above requirements in a QIO 
area and submit proposals for the contracts in accordance with this 
notice, we will consider those organizations to be potential sources 
for the 4 contracts upon their expiration. These organizations will be 
entitled to participate in a full and open competition for the QIO 
contract to perform the QIO statement of work.

(Catalog of Federal Domestic Assistance Program No. 93.773, 
Medicare--Hospital Insurance Program; and No. 93.774, Medicare-
Supplementary Medical Insurance Program)

    Dated: October 28, 2010.
Donald M. Berwick,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2010-28817 Filed 11-24-10; 8:45 am]
BILLING CODE 4120-01-P