Federal Register / Vol. 79, No. 249 / Tuesday, December 30, 2014 / Notices 78439 

authorization request can be completed 

by the (ordering) physician or treating 

practitioner and submitted to the 

appropriate DME MAC for an initial 

decision. The supplier may also submit 

the request on behalf of the physician or 

treating practitioner. The physician, 

treating practitioner or supplier who 

submits the request on behalf of the 

physician or treating practitioner, is 

referred to as the ‘‘submitter.’’ Under 

this demonstration, the submitter will 

submit to the DME MAC a request for 

prior authorization and all relevant 

documentation to support Medicare 

coverage of the PMD item. Form 

Number: CMS–10421 (OMB control 

number: 0938–1169); Frequency: 

Occasionally; Affected Public: State, 

Local or Tribal Governments; Number of 

Respondents: 333,750; Total Annual 

Responses: 333,750; Total Annual 

Hours: 170,060. (For policy questions 

regarding this collection contact Daniel 

Schwartz at 410–786–4197.) 

Dated: December 23, 2014. 

Martique Jones, 

Director, Regulations Development Group, 

Office of Strategic Operations and Regulatory 

Affairs. 

[FR Doc. 2014–30468 Filed 12–29–14; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3296–FN] 

RIN 0938–ZB14 

Medicare Program; Evaluation Criteria 

and Standards for Beneficiary and 

Family Centered Care Quality 

Improvement Organization Contract 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

ACTION: Final notice. 

SUMMARY: This final notice announces 

the general criteria we will use to 

evaluate the effectiveness and efficiency 

of Beneficiary and Family Centered Care 

(BFCC) Quality Improvement 

Organizations (QIOs) that entered into 

contracts with CMS under the 11th 

Statement of Work (SOW) in May 2014. 

The activities for the BFCC–QIO SOW 

began August 1, 2014. (This contract 

allows for a transition period from the 

incumbent QIOs to the successor QIOs.) 

In addition, this notice addresses the 

public comments received on the July 

28, 2014 notice with comment period 

entitled, ‘‘Evaluation Criteria and 

Standards for Beneficiary and Family 

Centered Care Quality Improvement 

Organization Contracts.’’ 

DATES: Effective Dates: August 1, 2014 

to July 31, 2019. 

FOR FURTHER INFORMATION CONTACT: 

Alfreda Staton, (410) 786–4194. 

SUPPLEMENTARY INFORMATION: 

I. Background 

Section 1153(h)(2) of the Social 

Security Act (the Act) requires the 

Secretary of the Department of Health 

and Human Services (the Secretary) to 

publish in the Federal Register the 

general criteria and standards that will 

be used to evaluate the effective and 

efficient performance of contract 

obligations by the Quality Improvement 

Organizations (QIOs) and to provide the 

opportunity for public comment with 

respect to these criteria and standards. 

II. Provisions of the Notice With 

Comment Period 

On July 28, 2014, we published a 

notice with comment period in the 

Federal Register (79 FR 43747 through 

43749) entitled, ‘‘Evaluation Criteria 

and Standards for Beneficiary and 

Family Centered Care Quality 

Improvement Organization Contracts,’’ 

announcing the general criteria we 

would use to evaluate the effectiveness 

and efficiency of Beneficiary and Family 

Centered Care (BFCC) Quality 

Improvement Organizations (QIOs) that 

entered into contracts with CMS under 

the 11th Statement of Work (SOW) in 

May 2014 (HHSM–500–2014–RFP– 

BFCC–QIO). That notice generally 

summarized the tasks of the BFCC–QIOs 

and the criteria to be used for annual 

performance evaluations during the 5- 

year term of the contract. BFCC–QIO 

performance under the 11th SOW 

contract began on August 1, 2014, after 

a transition period. 

The tasks of the BFCC–QIOs under 

the BFCC–QIO 11th SOW contract are as 

follows: 

• Quality of care reviews, including 

beneficiary complaint and general 

quality of care reviews. 

• Beneficiary appeals of denials of 

hospital admissions discharge and 

terminations of services decisions 

commonly referred to as Grijalva, BIPA, 

and Weichardt appeals. 

• Medical necessity reviews. 

• Appropriateness of setting reviews. 

• Diagnosis Related Group (DRG) 

reviews. 

• Readmission reviews. 

• Reviews under Emergency Medical 

Treatment and Active Labor Act 

(EMTALA). 

• Sanctions. 

• Monitoring of Physician 

Acknowledgement Statements under 

section 1156(a) of the Act and our 

regulations at 42 CFR 412.46. 

Evaluation of the Tasks Measures 

The measures of BFCC–QIO 

performance for the 11th SOW are as 

follows: 

• Quality of Review: Inter-Rater 

Reliability. 

• 4-day Data Entry Compliance. 

• Timeliness of Beneficiary 

Complaints and Other Quality of Care 

Reviews. 

• Timeliness of Discharge/Service 

Termination Reviews. 

• Timeliness of EMTALA and Higher 

Weighted Diagnosis-Related Group 

Reviews. 

• Complainant Agreement to 

Complete Survey. 

• Beneficiary Experience with 

Quality of Care Complaints. 

• Beneficiary Experience with Appeal 

Reviews. 

Evaluation Criteria 

The Annual and 54th Month 

Evaluation Criteria for each of these 

measures are specifically defined in 

Attachment J–10, ‘‘Annual and 54th 

Month Evaluation Criteria Measures 

Table,’’ of the BFCC–QIO SOW; the 

criteria for evaluating each deliverable 

are identified in Schedule F of the 11th 

SOW. Additional detail is provided in 

the notice posted at: http://

www.gpo.gov/fdsys/pkg/FR-2014-07-28/

pdf/2014-17625.pdf. 

III. Analysis of and Responses to Public 

Comments on the Notice With Comment 

Period 

Two commenters submitted several 

comments concerning the general 

criteria we would use to evaluate the 

effectiveness and efficiency of BFCC– 

QIOs that will enter into contracts with 

CMS under the 11th SOW. One 

commenter was affiliated with a private 

healthcare quality improvement entity 

and the other commenter was with a 

healthcare quality improvement 

association. A summary of the 

comments and our responses are as 

follows: 

Comment: Both commenters 

expressed concern with potential public 

perception of bias arising from the 

evaluation criterion that considers of 

beneficiary experience with the quality 

of care complaints and appeal reviews 

as part of the evaluation of the BFCC– 

QIO’s performance of quality-of-care 

and other statutory and regulatory 

reviews and appeals. The commenters 

indicated that consideration of 

beneficiary experience with the quality 

of care complaints and appeal reviews 

as part of the evaluation of the BFCC– 

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78440 Federal Register / Vol. 79, No. 249 / Tuesday, December 30, 2014 / Notices 

QIO’s performance might lead to the 

erroneous perception by the public that 

reviews or appeals may be biased either 

toward the beneficiary (when obtaining 

beneficiary feedback), or toward 

providers (when obtaining provider 

feedback). One commenter encouraged 

CMS to carefully consider public 

perception of the evaluation criterion of 

beneficiary experience with the quality 

of care complaints and appeal reviews. 

The other commenter suggested 

removing customer feedback from the 

evaluation criteria. 

Response: We appreciate the concern 

with maintaining the integrity of public 

perception of our oversight of the 

performance of numerous statutory and 

regulatory review functions to safeguard 

beneficiaries. The evaluation criteria 

and standards include safeguards to 

monitor the quality of the reviews, such 

as inter-rater reliability, the QIOs’ 

timeliness in completing the reviews 

and ongoing monitoring of the BFCC– 

QIO’s internal quality control program. 

The beneficiary satisfaction survey 

allows CMS to monitor the QIOs’ ability 

to provide superior customer service 

while incorporating processes that 

engage beneficiaries and their 

representatives in ways that are patient 

and family centered. With appropriate 

monitoring and safeguards, we benefit 

from consideration of beneficiaries’ 

experience with the review and appeals 

process while maintaining consistently 

high levels of program integrity. 

Comment: One commenter agreed 

with the importance of instituting 

rigorous standards for inter-rater 

reliability and suggested that CMS 

consider developing evaluation 

standards that assess the accuracy as 

well as reliability of reviews. 

Response: We agree with the 

importance of reliable and accurate 

reviews relating to the execution of the 

numerous statutory and regulatory 

review functions to safeguard 

beneficiaries. The evaluation criteria 

includes annual (and at the 54th month) 

assessment of minimum performance 

criteria for inter-rater reliability. 

Additionally, we will monitor the 

quality program in place at each BFCC– 

QIO to ensure that the work is both 

reliable and accurate. We agree on the 

merits of developing more formal 

evaluation standards and criteria for 

assessing the validity of work by BFCC– 

QIO reviewers. We intend to investigate 

suitable measures for consideration in 

the future. 

Comment: Both commenters noted the 

potential for external factors and 

perhaps the outcome of the review or 

appeal itself to influence the 

beneficiaries’ experience and their 

willingness to participate in the survey 

process. One commenter stated that 

there should be careful consideration of 

these factors in the evaluation standards 

and criteria; the other commenter 

recommended not using beneficiary 

participation in the survey as part of the 

evaluation. 

Response: We believe that the BFCC– 

QIOs must exercise diplomacy, 

professionalism and compassion in their 

performance of numerous statutory and 

regulatory review functions to safeguard 

beneficiaries. Our monitoring of the 

internal quality control processes of the 

BFCC–QIOs and ongoing monitoring 

activities focuses in part on the 

professionalism in their interactions 

with beneficiaries and their 

representatives. We recognize that 

external factors may, to some limited 

extent, have an impact on the 

beneficiaries’ willingness to participate 

in the survey of their experience with 

the appeal or review process. However, 

based on previous experience with these 

surveys, we are confident that the 

proficiency of the work by the BFCC– 

QIO with beneficiaries or their 

representatives will be the dominant 

factor that impacts the willingness by 

beneficiaries or their representatives to 

participate in the survey. 

Comment: Both commenters indicated 

that although the BFCC–QIO is 

primarily responsible for its 

performance on the evaluation 

standards and criteria, external factors 

outside the control of the BFCC–QIO 

may also impact performance on 

measures such as timeliness (of 

Beneficiary Complaints and Other 

Quality of Care Reviews, Discharge/

Service Termination Reviews, and 

EMTALA and Higher-Weighted 

Diagnosis Related Group Reviews). Both 

commenters suggested that we consider, 

if appropriate, factors outside the 

control of the contractors. 

Response: We agree with the 

commenters that there are certain 

factors, such as natural calamities, for 

example, hurricanes or earthquakes, in 

addition to transitional issues at the 

beginning and end of the contract cycle 

that may, despite the best mitigating 

efforts, have an impact on the BFCC– 

QIO’s ability to conduct work in specific 

regions. We are confident that these 

extraordinary circumstances can be 

addressed using our intervention and 

evaluation standards and criteria. 

Comment: One commenter noted the 

importance of the BFCC–QIO’s Internal 

Quality Control (IQC) Program but 

recommended that we consider only 

whether the BFCC–QIO had a process in 

place and not the quality and 

competence of the execution of the IQC. 

Response: We agree with the 

importance of the BFCC–QIO instituting 

an IQC Program. However, we believe 

that it is in the Government’s and 

beneficiaries’ best interest to conduct 

ongoing monitoring to ensure that the 

IQC is kept current and accurately 

reflects the competent execution of the 

BFCC–QIO’s performance of numerous 

statutory and regulatory review 

functions to safeguard beneficiaries. We 

plan to use ongoing monitoring of the 

IQC as a critical element to inform 

discussions with the BFCC–QIO on their 

improvement efforts. 

IV. Provisions of the Final Notice 

We have analyzed these comments 

and determined that it is appropriate to 

finalize without modification the 

provisions set forth in the July 28, 2014 

notice with comment period entitled, 

‘‘Evaluation Criteria and Standards for 

Beneficiary and Family Centered Care 

Quality Improvement Organization 

Contracts.’’ (79 FR 43747 through 

43749). 

V. Collection of Information 

Requirements 

This document does not impose 

information collection requirements, 

that is, reporting, recordkeeping or 

third-party disclosure requirements. 

Consequently, there is no need for 

review by the Office of Management and 

Budget under the authority of the 

Paperwork Reduction Act of 1995. 

VI. Regulatory Impact Statement 

In accordance with the provisions of 

Executive Order 12866, this notice was 

not reviewed by the Office of 

Management and Budget. 

Dated: November 19, 2014. 

Marilyn Tavenner, 

Administrator, Centers for Medicare & 

Medicaid Services. 

[FR Doc. 2014–30448 Filed 12–29–14; 8:45 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

Centers for Medicare & Medicaid 

Services 

[CMS–3300–FN] 

RIN 0938–ZB15 

Medicare Program; Evaluation Criteria 

and Standards for Quality 

Improvement Networks Quality 

Improvement Program Contracts; Base 

and Task Orders 

AGENCY: Centers for Medicare & 

Medicaid Services (CMS), HHS. 

mstockstill on DSK4VPTVN1PROD with NOTICES