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[Federal Register Volume 79, Number 249 (Tuesday, December 30, 2014)]
[Notices]
[Pages 78439-78440]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2014-30448]

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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.

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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-

[[Page 78440]]

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
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