CMS Issues Proposed Rule on Rights of Beneficiaries to Make Complaints to Quality Improvement Organizations (QIOs)

On February 2, 2011, the Centers for Medicare and Medicaid Services (“CMS”) issued a proposed rule in the Federal Register, 76 FR 5755, that requires most Medicare providers and suppliers to provide written notice to beneficiaries of their right to lodge quality of care complaints with Quality Improvement Organizations (QIOs).

CMS contracts with a QIO in each state. QIOs are mostly private organizations staffed by health care professionals that CMS has trained to review the quality of medical care, help Medicare beneficiaries with complaints about care, and to implement improvements in the quality of care provided by Medicare providers and suppliers. CMS’ mission for the QIO Program is to improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.

Under current CMS regulations, only beneficiaries admitted to hospitals as inpatients are required to receive information about contacting QIOs regarding quality of care issues. The proposed rule vastly expands the requirements to cover many providers and suppliers and requires them to inform beneficiaries of their right to complain to a QIO about quality of care, as well as how to contact their local QIO. The following providers and suppliers are affected by the proposed rule:

  • Clinics, rehabilitation agencies, and public health agencies that provide outpatient physical therapy and speech-language-pathology services
  • Comprehensive outpatient rehabilitation facilities
  • Critical access hospitals
  • Home health agencies
  • Hospices
  • Hospitals
  • Long-term care facilities
  • Ambulatory Surgical Centers
  • Portable x-ray services
  • Rural health clinics and Federally Qualified Health Centers

The proposed rules revise the patient or resident rights regulatory provisions for providers and suppliers to provide that –

– On admission, providers and suppliers must inform all Medicare beneficiaries by written notice of their right to file a written complaint with the QIO in the State were services are being or were provided about the quality of care they are receiving or have received.
– the written notice must contain the name of the QIO, its mailing address, electronic mail address, and telephone number.
– the provider or supplier must document in the beneficiary’s record that the written notice was presented to the beneficiary or beneficiary’s representative or surrogate.

Once the rule becomes final, providers and suppliers will have to revise patient and resident rights statements to include these requirements and change policies, as needed, to ensure that documentation that patients or residents received the information is present in the appropriate clinical records.

Additionally, providers and suppliers should recognize that with increased consumer awareness of an additional avenue to pursue complaints about care there will likely be an increase in QIO activity and interaction with QIOs.

A copy of the proposed rule can be found here —–> Proposed Rule

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