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GAO-11-116R 1 (2010-12-06)

handle is hein.gao/gaobaanvr0001 and id is 1 raw text is: GGAO Acountabi ty I Integrity * Reliability United States Government Accountability Office Washington, DC 20548 December 6, 2010 The Honorable Max Baucus Chairman The Honorable Charles E. Grassley Ranking Member Committee on Finance United States Senate Subject: Medicare: CMS Needs to Collect Consistent Information from Quality Improvement Organizations to Strengthen Its Establishment of Budgets for Quality of Care Reviews Medicare funds health care services for more than 46 million beneficiaries.' The Centers for Medicare & Medicaid Services (CMS)-the agency that administers Medicare-contracts with private organizations known as Quality Improvement Organizations (QIO) to, among other core functions, improve the quality of care for Medicare beneficiaries. CMS contracts with one QIO for each of the 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. One of the QIOs' many responsibilities is to review quality of care concerns, raised by Medicare beneficiaries or others, to determine whether Medicare-financed medical services meet professionally recognized standards of health care.2 Quality of care reviews may address a range of issues, such as inappropriate treatment or hospital staff not administering medications on time; may involve a variety of health care services and settings; and may include a range of Medicare providers or practitioners.3 'Medicare is the federal health insurance program for people over age 65, individuals under age 65 with certain disabilities, and individuals diagnosed with end-stage renal disease. 2QIOs are required to conduct an appropriate review of all written quality of care concerns from Medicare beneficiaries, or their representatives, alleging that the quality of services they received did not meet professionally recognized standards of health care. 42 U.S.C. § 1320c-3(a)(14); see also 42 C.F.R. § 476.71(a)(2) (2009). QIOs are also required by their contracts to review such concerns from CMS or CMS-designated entities, such as Medicare Administrative Contractors, the CMS contractors whose responsibilities include processing and paying Medicare claims. Professionally recognized standards of health care are defined as statewide or national standards of care, whether in writing or not, that professional peers, such as physicians, recognize as applying to their fellow peers practicing or providing care within a state. See 42 C.F.R. § 1001.2 (2009). 3For the purposes of quality of care reviews, a provider is defined as a hospital or other health care facility, agency, or organization and a practitioner is defined as a physician or other health care professional licensed under state law to practice his or her profession. See 42 C.F.R. § 1004.1 (2009). GAO-11-116R Medicare Quality of Care Reviews

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