[Federal Register Volume 60, Number 85 (Wednesday, May 3, 1995)]
[Notices]
[Pages 21824-21825]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 95-10793]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Health Care Financing Administration
[HSQ-227-N]


Medicare Program; Peer Review Organization Contracts: 
Solicitation of Statements of Interest From In-State Organizations--
Alaska, Delaware, the District of Columbia, Idaho, Kentucky, Maine, 
Nebraska, Nevada, South Carolina, Vermont, and Wyoming

AGENCY: Health Care Financing Administration (HCFA), HHS.

ACTION: General notice.

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SUMMARY: This notice, in accordance with section 1153(i) of the Social 
Security Act, announces the scheduled expiration dates of the current 
contracts between HCFA and several out-of-State Utilization and Quality 
Control Peer Review Organizations. It also specifies the period of time 
in which in-State organizations may submit a statement of interest so 
that they may be eligible to compete for these contracts. The States 
currently affected and their respective expiration dates are as 
follows:

Delaware..........................................  March 31, 1996.     
Nevada............................................  March 31, 1996.     
Wyoming...........................................  March 31, 1996.     
Alaska............................................  June 30, 1996.      
District of Columbia..............................  June 30, 1996.      
Idaho.............................................  June 30, 1996.      
Maine.............................................  June 30, 1996.      
Vermont...........................................  June 30, 1996.      
Nebraska..........................................  September 30, 1996. 
Kentucky..........................................  September 30, 1996. 
South Carolina....................................  September 30, 1996. 
                                                                        

DATES: Written statements of interest must be received at the address 
specified no later than 5 p.m. EST, June 2, 1995. Due to staffing and 
resource limitations, we cannot accept statements submitted by 
facsimile (FAX) transmission.

ADDRESSES: Statements of interest must be submitted to--Health Care 
Financing Administration, OFHR, OAG, Attn.: Brian Hebbel, Room G-M-1, 
East Low Rise Building, 6325 Security Boulevard, Baltimore, Maryland 
21207.

FOR FURTHER INFORMATION CONTACT: Kathleen Kelso, (410) 966-7214.

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 Social Security Act (the Act) by 
establishing the Utilization and Quality Control Peer Review 
Organization (PRO) program. Congress created the PRO program in order 
to redirect, simplify, and enhance the cost-effectiveness and 
efficiency of the peer review process.
    PROs currently review certain health care services furnished under 
Title XVIII of the Act (Medicare) and under certain other Federal 
programs to determine whether those services are reasonable, medically 
necessary, furnished in the appropriate setting, and are of a quality 
that meets professionally recognized standards. PRO activities are a 
part of the Health Care Quality Improvement Program (HCQIP) that 
supports HCFA's mission of assuring health care security for its 
eligible beneficiaries. The HCQIP is carried out locally by the PRO in 
each State. Under the HCQIP, PROs provide information for health care 
plans, providers, and practitioners to improve the quality of care 
furnished to Medicare beneficiaries.
    In June 1984, HCFA began awarding contracts to PROs. We currently 
maintain 53 PRO contracts with organizations that provide medical 
review activities for 49 of the United States, the District of 
Columbia, Puerto Rico, and the Virgin Islands. The organizations that 
are eligible to contract as PROs have satisfactorily demonstrated that 
they are either physician-sponsored or physician-access organizations 
in accordance with sections 1152 and 1153 of the Act and our 
regulations at 42 CFR 462.102 and 462.103. A physician-sponsored 
organization is one that is both composed of a substantial number of 
the licensed doctors of medicine or osteopathy practicing medicine or 
surgery in the respective review area and is 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 assure adequate peer review of the services furnished by the 
various medical specialties and subspecialties. In addition, the 
organization must not be a health care facility, health care facility 
association, or a health care facility affiliate, and 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 a new subsection (i) that 
prohibits the Secretary from renewing the contract of any PRO that is 
not an in-State organization 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 of expiration, 
and must specify the period of time during which an in-State 
organization may submit a proposal for the contract. If one or more 
qualified in-State organizations submits a proposal within the 
specified period of time, HCFA may not automatically renew the contract 
on a noncompetitive basis but must instead provide for competition for 
the contract in the same manner used for a new contract. An in-State 
organization is defined as an organization that has its primary place 
of business in the State in which review will be conducted or that is 
owned by a parent corporation, the headquarters of which is located in 
that State.
    There are currently 11 PRO contracts with entities that do not meet 
the statutory definition of an in-State organization. The areas 
affected for purposes of this notice are Alaska, Delaware, the District 
of Columbia, Idaho, Kentucky, Maine, Nebraska, Nevada, South Carolina, 
Vermont, and Wyoming.

II. Provisions of the Notice

    This notice announces the scheduled expiration dates of the current 
contracts between HCFA and the out-of-State PROs responsible for review 
in Alaska, Delaware, the District of Columbia, Idaho, Kentucky, Maine, 
Nebraska, Nevada, South Carolina, Vermont, and Wyoming. Interested in-
State organizations may submit statements of interest to be the PRO for 
the aforementioned States. The statements must be received by HCFA no 
later than June 2, 1995. In its statement of interest, the organization 
must furnish materials [[Page 21825]] that demonstrate that it meets 
the definition of an in-State organization. Specifically, the 
organization must have its primary place of business in the State in 
which review will be conducted or be owned by a parent corporation, the 
headquarters of which is located in that State. In its statement, 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
    i. 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, and be representative of the physicians 
practicing in the review area.
    ii. The organization must not be a health care facility, health 
care facility association, or health care facility affiliate.
    iii. In order to meet the substantial number requirement of A.l.i., 
an organization must be 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 requirement of 
A.l.i., 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; or, 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, then the organization must demonstrate in its 
statement of interest, 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
    i. 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 assure adequate peer review of the services provided by the 
various medical specialties and subspecialties.
    ii. The organization must not be a health care facility, health 
care facility association, or health care facility affiliate.
    iii. An organization meets the requirements of A.2.i. 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 PRO 
area, and submit statements of interest in accordance with this notice, 
HCFA will consider those organizations to be potential sources for the 
aforementioned contracts upon their expiration. These organizations 
will be entitled to participate in a full and open competition for the 
PRO contract to provide medical review services.

III. Information Collection Requirements

    This notice contains information collection requirements that have 
been approved and assigned Control Number OMB 0938-0526 by the Office 
of Management and Budget under the authority of the Paperwork Reduction 
Act of 1980 (44 U.S.C. 3501 et seq.). This approval expires on October 
31, 1997.

IV. Other

    In accordance with the provisions of Executive Order 12866, this 
regulation was not reviewed by the Office of Management and Budget.

    Authority: Section 1153 of the Social Security Act (42 U.S.C. 
1320c-2).

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

    Dated: March 23, 1995.
Bruce C. Vladeck,
Administrator, Health Care Financing Administration.
[FR Doc. 95-10793 Filed 5-2-95; 8:45 am]
BILLING CODE 4120-01-P