[Federal Register Volume 72, Number 151 (Tuesday, August 7, 2007)]
[Notices]
[Pages 44150-44155]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-15342]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3188-NC]


Medicare Program; Evaluation Criteria and Standards for Quality 
Improvement Program Organization Contracts

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice with comment period.

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SUMMARY: This notice with comment period describes the criteria we 
intend to use to evaluate the efficiency and effectiveness of Quality 
Improvement Organizations (QIOs) currently under contract with CMS in 
accordance with the Social Security Act. These evaluation criteria are 
based on the tasks and related subtasks set forth in the QIO's Scope of 
Work (SOW). The current 8th SOW includes Tasks 1, 3, and 4 (Task 2 is 
reserved) with subtasks included under Tasks 1 and 3. QIOs were awarded 
contracts for the 8th SOW, or 8th Round, for 3 years, with staggered 
starting dates beginning August 2005, November 2005, and February 2006. 
Comments on this notice will also be considered in the development of 
the 9th SOW.

DATES: To be assured of consideration, comments must be received at one 
of the addresses provided below, no later than 5 p.m. on September 6, 
2007.

ADDRESSES: In commenting, please refer to file code CMS-3188-NC. 
Because of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of four ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click 
on the link ``Submit electronic comments on CMS regulations with an 
open comment period.'' (Attachments should be in Microsoft Word, 
WordPerfect, or Excel; however, we prefer Microsoft Word.)
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address ONLY: Centers for Medicare & 
Medicaid

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Services, Department of Health and Human Services, Attention: CMS-3188-
NC, P.O. Box 8010, Baltimore, MD 21244-8010.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address only: Centers for 
Medicare & Medicaid Services, Department of Health and Human Services, 
Attention: CMS-3188-NC, Mail Stop C4-26-05, 7500 Security Boulevard, 
Baltimore, MD 21244-8010.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses. If you 
intend to deliver your comments to the Baltimore address, please call 
telephone number (410) 786-9994 in advance to schedule your arrival 
with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 
200 Independence Avenue, SW., Washington, DC 20201; or 7500 Security 
Boulevard, Baltimore, MD 21244-8010.
    (Because access to the interior of the HHH Building is not readily 
available to persons without Federal Government identification, 
commenters are encouraged to leave their comments in the CMS drop slots 
located in the main lobby of the building. A stamp-in clock is 
available for persons wishing to retain a proof of filing by stamping 
in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

FOR FURTHER INFORMATION CONTACT: Terry Lied (410) 786-8973.

SUPPLEMENTARY INFORMATION:
    Submitting Comments: We welcome comments from the public on all 
issues set forth in this notice with comment period to assist us in 
fully considering issues and developing policies. You can assist us by 
referencing the file code CMS-3188-NC and the specific ``issue 
identifier'' that precedes the section on which you choose to comment.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on 
CMS Regulations'' on that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

I. Background

    [If you choose to comment on issues in this section, please include 
the caption ``BACKGROUND'' at the beginning of your comments.]
    The Peer Review Improvement Act of 1982 (Title I, Subtitle C of 
Pub. L. 97-248) amended Part B of Title XI of the Social Security Act 
(the Act) to establish the Peer Review Organization (PRO) programs. The 
PRO program (now called the Quality Improvement Organization (QIO) 
program) was established to redirect, simplify, and enhance the cost-
effectiveness and efficiency of the medical peer review process. 
Sections 1152, 1153(b), and 1153(c) of the Act define the types of 
organizations eligible to become QIOs, and establish certain 
limitations and priorities regarding QIO contracting.
    The Secretary enters into contracts with QIOs to perform three 
broad functions:
     Improve quality of care for beneficiaries by ensuring that 
beneficiary care meets professionally recognized standards of health 
care;
     Protect the integrity of the Medicare Trust Fund by 
ensuring that Medicare pays only for services and items that are 
reasonable and medically necessary and that are provided in the most 
economical setting;
     Protect beneficiaries by expeditiously addressing 
individual cases such as beneficiary quality of care complaints, 
contested hospital issued notices of noncoverage (HINNs), alleged 
Emergency Medical Treatment and Labor Act (EMTALA) violations, and 
other statutory responsibilities.
    Section 1154 of the Act requires that QIOs review those services 
furnished by physicians; other health care practitioners; and 
institutional and non-institutional providers of health care services, 
including health maintenance organizations and competitive medical 
plans. Section 109 of the Medicare Prescription Drug, Improvement, and 
Modernization Act of 2003 (MMA), Public Law 108-173, amended section 
1154(a)(1) of the Act to expand the scope of review of QIOs to include 
Medicare Advantage Organizations, and prescription drug sponsors. 
Section 109 of the MMA also created a new section 1154(a)(17) of the 
Act, which requires QIOs to offer to providers, practitioners, Medicare 
Advantage Plans and prescription drug sponsors, quality improvement 
assistance pertaining to prescription drug therapy.
    Section 1153(h)(2) of the Act requires the Secretary to publish in 
the Federal Register the general criteria and standards that would be 
used to evaluate the efficient and effective performance of contract 
obligations by QIOs and to provide the opportunity for public comment. 
The QIO contracts for the 8th SOW were awarded for 3 years with 
starting dates staggered into three approximately equal groups (rounds) 
starting August 2005, November 2005, and February 2006, respectively. 
Comments on this notice will also be considered in the development of 
the 9th scope of work.

II. Measuring QIO Performance & Criteria for Non-Competitive Renewal of 
Contracts

    [If you choose to comment on issues in this section, please include 
the caption ``MEASURING QIO PERFORMANCE'' at the beginning of your 
comments.]
    Under the 8th Round contracts, QIOs are responsible for completing 
the requirements of the following specific tasks and subtasks:
    Task 1: Assisting Providers in Developing the Capacity for and 
Achieving Excellence.
    a. Subtask 1a: Nursing Home.
    b. Subtask 1b: Home Health.
    c. Subtask 1c1: Hospital.
    d. Subtask 1c2: Critical Access Hospital/Rural Hospital.
    e. Subtask 1d1: Physician Practice.
    f. Subtask 1d2: Physician Practice: Underserved Populations.
    g. Subtask 1d3: Physician Practice/Pharmacy: Part D Benefit.
    Task 2: Reserved.
    Task 3: Protecting Beneficiaries and the Medicare Program.
    a. Subtask 3a: Beneficiary Protection.
    b. Subtask 3b: Hospital Payment Monitoring Program
    Task 4: Special Studies and Projects (Special Studies defined as 
work that CMS directs a QIO to perform or work that a QIO elects to 
perform with CMS approval which is not currently defined

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under Tasks 1-3 of the SOW but falls within the scope of the contract 
and section 1154 of the Act).
    Under this SOW, to merit having its contract renewed non-
competitively, the QIO must meet the performance criteria on the tasks 
and subtasks. For Tasks 1 and 3, the QIO will be scored using the 
following four classifications:
     Excellent Pass
     Full Pass
     Conditional Pass
     Not Pass
    For all nine subtasks related to tasks 1 and 3, the QIO must 
achieve at least a Conditional Pass to be eligible to have its contract 
renewed non-competitively. A QIO that receives a ``Not Pass'' on any 
subtask will be invited to our evaluation panel (subject to CMS 
approval). In addition, the QIO must achieve at least a ``Full Pass'' 
or ``Excellent Pass'' on seven of the nine subtasks to be eligible to 
have its contract renewed non-competitively. A QIO that receives a 
``Conditional Pass'' on three or more subtasks will be invited to our 
evaluation panel (subject to CMS approval). However, an ``Excellent 
Pass'' on one or more subtasks may negate a ``Conditional Pass'' on one 
subtask. That is, a QIO that receives an ``Excellent Pass'' on one or 
more subtasks and receives a ``Conditional Pass'' on no more than three 
subtasks and does not receive a ``Not Pass'' on any subtasks may be 
eligible to have its contract renewed non-competitively. A QIO working 
only seven or eight subtasks due to valid exemptions as specified in 
the SOW will be treated as though it has received a ``Full Pass'' in 
the subtasks from which it is exempt. The QIO must still achieve at 
least a ``Full Pass'' or ``Excellent Pass'' on seven of the nine 
subtasks in order to have its contract non-competitively renewed.
    We may revise the performance criteria for a QIO before signing a 
contract with that QIO. The target performance levels for individual 
tasks and subtasks may vary across QIOs. We will provide these specific 
performance criteria during the Request for Proposal (RFP) process.
    We will assess the QIO's task and subtask-specific performance in 
November 2007 based on the data available at that time. The specific 
evaluation criteria are described below for each task and subtask. Task 
4 (special projects) will not be subject to these evaluation criteria. 
Projects funded to reduce hospital payment error under Task 4 will 
affect QIOs evaluation as specified in Task 3b. The assessment of 
performance on all other special projects under Task 4 will affect the 
QIO's eligibility to receive funding for additional special projects 
under the current or subsequent QIO contracts, but will not affect 
eligibility for non-competitive renewal of the QIO contract.
    For the 9th SOW, we intend to revise the criteria required for non-
competitive renewal of contracts. For the 9th SOW, we are considering a 
requirement that QIOs achieve a ``full pass'' or an ``excellent pass'' 
on all tasks and sub-tasks for the non-competitive renewal of their 
contracts for the 10th SOW. We are also reviewing the process by which 
a QIO contract can be terminated, during the course of a SOW, on 
performance grounds.

III. Standards for Minimum Performance

    [If you choose to comment on issues in this section, please include 
the caption ``STANDARDS FOR MINIMUM PERFORMANCE'' at the beginning of 
your comments.]

Task 1: Assisting Providers in Developing the Capacity for and 
Achieving Excellence

    Subtasks of Task 1 will include statewide and identified 
participant components. (The term ``statewide'' is used for activities 
directed toward a QIO's entire State/jurisdiction--that is, one of the 
50 States, the District of Columbia, Puerto Rico, or the Virgin 
Islands.) Subtask evaluation will be based on the following five 
dimensions of performance:
     Performance measure results (changes and improvements in 
rates).
     Clinical performance reporting (increases in number of 
measures reported).
     Providers' adoption and use of systems.
     Implementation of key process changes.
     Changes in organizational culture.
    Each subtask of Task 1 will include a requirement to meet 
Satisfaction and Knowledge/Perception performance criteria for provider 
identified participants (IPG) and non-identified participants (Non-
IPG). Satisfaction and knowledge/perception surveys and stakeholder 
knowledge/perception surveys will be used to measure performance. 
``Identified Participants'' are providers that received focused 
assistance on at least one quality measure from QIOs. ``Non-Identified 
Participants'' are providers that received no focused assistance from 
QIOs.
Task 1a: Nursing Home
    Under Task 1a, the QIO will focus on the following:
     Improving clinical performance.
     Setting improvement targets.
     Measuring the nursing home experience.
    The QIO will focus on decreasing the rate of pressure ulcers among 
high risk individuals, decreasing the use of physical restraints, 
improving the management of depressive symptoms, and improving the 
management of pain in chronic (long stay) residents among a select 
group of identified participant nursing homes (IPG1) as well as other 
nursing homes requesting assistance from the QIO. The QIO must also 
work with a second select group of identified participants (IPG2) that 
focuses on decreasing the rate of pressure ulcers among high risk 
individuals and decreasing the use of physical restraints.
    The QIO will set statewide targets for (at a minimum) pressure 
ulcers among high-risk residents and physical restraints. In addition, 
the QIO will work with all nursing homes throughout the State/
jurisdiction to set quality improvement targets for (at a minimum) 
pressure ulcers and physical restraints on an annual basis.
    In the area of organizational culture, the QIO must work with both 
groups of identified participants (IPG1 and IPG2) to collect 
information on resident and staff experience/satisfaction with care and 
staff turnover by engaging in activity that is likely to improve 
organizational culture. (Note: In four States/jurisdictions (WY, AK, 
DC, and PR), the QIO must work with its Project Officer to develop 
alternative Task 1a evaluation criteria for this SOW. The QIO must 
receive approval from its Project Officer and the Task 1a Government 
Task Leader (GTL) on its alternative Task 1a evaluation criteria).
Task 1b: Home Health
    QIO work in the home health setting will focus at the statewide 
level on meeting or exceeding the statewide targets on the Outcome and 
Assessment Information Set (OASIS). Information on OASIS can be found 
at http://www.cms.hhs.gov/OASIS/. In addition, the QIO must work with 
home health agencies (HHAs) in setting targets for acute care 
hospitalization and other publicly reported OASIS measures to be 
determined by CMS. The QIO must also work to increase the number of 
HHAs that incorporate an assessment of influenza and pneumococcal 
vaccination status into the patient comprehensive assessment, offer 
these vaccinations, and provide follow-up. The QIO must also work with 
two groups of identified participants: A Clinical Performance 
Identified Participant Group (IPG) and a Systems Improvement and 
Organizational

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Culture Change (SIOC) IPG. The QIO will focus in the Clinical 
Performance IPG on meeting or exceeding the IPG target on the OASIS 
measure for acute care hospitalization and one additional HHA-selected 
publicly reported OASIS measure through the Outcome Based Quality 
Improvement (OBQI) process. Information on OBQI can be found at: http://www.cms.hhs.gov/HomeHealthQualityInits/16_HHQIOASISOBQI.asp. With the 
SIOC IPG, the QIO will work to implement and/or use emerging telehealth 
technologies to help reduce acute care hospitalization and work to 
build capacity within these HHAs to evaluate and improve organizational 
culture. Both at the statewide level and with a Clinical Performance 
IPG, the QIO must improve clinical performance measure results. The QIO 
will be evaluated on its ability to work with HHAs to incorporate 
influenza and pneumococcal immunizations into the comprehensive patient 
assessment. The QIO will also be evaluated on the following:
     Implementation of a CMS survey tool that measures specific 
dimensions of organizational culture change.
     Submission by an HHA of a Plan of Action (POA) based on 
the results of the organizational culture change survey and 
implementation of a quality improvement activity.
     The QIO will have extra credit added to its total Task 1b 
evaluation score for improving results on both the OASIS acute care 
hospitalization measure and the selected publicly reported OASIS 
outcome measure.
    The QIO may receive extra credit for one or more of the following:
     Improving results for the identified participant OASIS 
measure.
     Improving results for the statewide and identified 
participant Acute Care Hospitalization measure.
     Improving the statewide immunization assessment rate 
beyond the target rate.
     Working with HHAs to set targets.
Task 1c1: Hospital
    For Task 1c1, the QIO must work with hospitals to achieve system-
level changes through the use of four strategies: Increasing clinical 
performance measurement and reporting; process improvement; systems 
improvement; and organizational culture change. The QIO will work to 
improve quality of care in hospitals through several distinct efforts 
aligned with each strategy. For clinical performance measure results, 
the QIO will assist an IPG, including both rural and urban Prospective 
Payment System (PPS) hospitals, in improving performance on an 
Appropriate Care Measure (ACM). (The ACM is defined as a composite 
measure of care at the patient level for three clinical topics--AMI, 
HF, and PNE.) The QIO will work at the statewide level to encourage 
hospitals to submit data on the full Hospital Quality Alliance (HQA) 
measure set of 22 measures (http://www.cms.hhs.gov/HospitalQualityInits/15_HospitalQualityAlliance.asp.). The QIO will 
also work to increase the validity of all data the hospitals submit to 
the QIO Clinical Data Warehouse.
    With a major focus on process improvement in this SOW, the QIO will 
work through statewide and identified participant efforts to get 
hospitals to adopt standard processes of care in five different areas: 
Prevention of surgical site infections, cardiovascular complications, 
venous thromboembolism, ventilator-associated pneumonia, and promotion 
of the use of fistulas for hemodialysis.
    To encourage systems improvement and organizational culture change, 
the QIO will work with identified participants (including both PPS and 
Critical Access Hospitals (CAHs)) to engage senior hospital leadership 
in the use of Computerized Physician Order Entry (CPOE), barcoding, 
and/or telehealth systems.
Task 1c2: Critical Access Hospital/Rural PPS Hospital
    The QIO must promote transformational change in CAHs and rural PPS 
hospitals by working on clinical performance quality measures and 
organizational safety culture relevant to the care provided in these 
hospitals. For purposes of Task 1c2, a rural PPS hospital is defined as 
a PPS hospital located in a non-Metropolitan Statistical Area (non-MSA) 
county. The QIO must assist identified participant CAHs/rural PPS 
hospitals in assessing their organizational safety culture. The QIO 
must also assist these hospitals in selecting, testing, and 
implementing changes that will demonstrate improvement in the 
organization's safety culture.
Task 1d1: Physician Practice
    The QIO will work with physician practice sites statewide and with 
an IPG. With an IPG, the QIO will focus on more reliable delivery of 
preventive services and effective management of patients with chronic 
conditions, in particular diabetes and heart disease. Working with 
their IPG, the QIO will seek to demonstrate improvement in clinical 
performance measures through the production and effective use of 
electronic clinical information (ECI) in conjunction with redesign of 
patient care processes within the physician practice sites.
    In addition to executing the work described for Task 1d1, the QIO 
will work with other organizations and agencies that have similar 
goals. The QIO must be actively involved with or promote the convening 
of local multi-stakeholder organizations that seek to promote the 
production and use of electronic clinical information and healthcare 
information exchange necessary for improving clinical performance. The 
QIO may work with these organizations to:
     Provide information on products, functionality, value, and 
costs of ECI systems;
     Promote production and use of ECI;
     Promote ECI sharing in accordance with the Health 
Insurance Portability and Accountability Act standards (including the 
Privacy and Security Rules) and QIO confidentiality requirements, as 
applicable; and
     Promote improved healthcare through use of and reporting 
of performance on the clinical quality measures specified for this 
Task.
    The QIO must work with physician practice sites and others to 
improve care for Medicare beneficiaries on a statewide basis. The QIO 
must support quality initiatives including the Physician Voluntary 
Reporting Program (PVRP) by activities that include providing 
information to physicians on participation in the initiative and on 
physician performance and improvement for those that report.
    The QIO must promote statewide quality improvement by working with 
public health, provider groups, and other broad-based agencies to 
support the use of appropriate preventive and disease-based care 
processes.

Medicare Advantage

    The Project Officer will evaluate performance based on the 
assistance provided to Medicare Advantage Organizations. The Medicare 
Advantage part of Task 1d1 will be waived for States/jurisdictions that 
had low MA enrollment among the eligible Medicare beneficiaries during 
calendar year 2004. Clinical Performance Measurement and Reporting:
    The objective of this element is to encourage physician practice 
sites to submit data on the DOQ clinical measures to the QIO Data 
Warehouse for all Medicare patients. Practice sites must demonstrate an 
ability to submit data to the Data Warehouse.
    The QIO must collaborate with the Medicare Care Management

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Performance Demonstration (section 649 of MMA) contractors by providing 
them with physician practice information the QIO already has or will 
collect, acquire, or generate in performing its own QIO tasks, provided 
the individual practices have requested and agreed to these 
disclosures. The QIO will be evaluated using the criteria deemed 
acceptable by CMS as outlined in the QIO's proposal.
Task 1d2:
    As part of QIO efforts in the physician practice setting, the QIO 
must, at the statewide level, work to improve clinical performance 
measure results for clinical quality indicators in the areas of 
diabetes, mammography, and adult immunizations for underserved racial/
ethnic populations.
    With one IPG, the QIO will work to promote systems improvement 
through DOQ activities with a representative underserved population 
under Task 1d1. With a Task 1d2-specific IPG, the QIO will work on 
practice site and practitioner system changes related to Culturally and 
Linguistically Appropriate Services (CLAS) standards and culturally 
competent care. For more information on CLAS standards refer to: http://www.omhrc.gov/templates/browse.aspx?lvl=2&lvlID=15.
    Task 1d2 is composed of core and non-core tasks. The core tasks 
include satisfactory completion of the CLAS/Cultural Competency IPG at 
the practice site and practitioner level and the Satisfaction and 
Knowledge/Perception survey for the relevant respondents. The non-core 
task is statewide measure improvement. Satisfactory completion of the 
core tasks will achieve a Full Pass for Task 1d2.
Task 1d3: Physician Practice/Pharmacy: Part D Benefit
    As part of QIO efforts in the physician practice setting in this 
SOW, the QIO must focus on improving safety in the delivery of 
prescription drugs. Widespread use of e-prescribing with comprehensive 
decision support tools is expected to improve the quality of 
prescription drug delivery. Until this broader use is in place, the QIO 
must implement quality improvement projects focusing on improved 
prescribing, using evidence-based guidelines.
    Over the course of the 8th SOW contract, we will work with the QIO 
to develop and implement new methods to gather and disseminate better 
evidence for healthcare decision-making. This activity will include 
collection, linkage, and de-identification of Part D and other public 
and private administrative data; assisting in implementation of 
clinical registries and practical clinical trials; and other work 
necessary to support the development and use of better evidence for 
decisions.
    A variety of methods are available to accomplish these activities. 
We support engaging physicians because improving prescribing begins 
with modifying physicians' behavior. This can be accomplished by 
providing data and information in ways that support behavior change. We 
also support working with dispensing pharmacists because they detect 
errors and problems with the medications they dispense, and they 
interact with beneficiaries. Pharmacy policies, procedures, and quality 
checks need to be implemented to be consistent with quality, safety, 
and cost-effectiveness goals.
    By partnering with prescription drug plans (PDPs) and using the 
drug data available, the QIO can affect prescribing by physicians and 
improve delivery of services at the pharmacy level. Medicare Advantage 
PDPs will have similar goals as fee-for-service (FFS) Medicare PDPs and 
will have both more information and more direct control than FFS 
Medicare PDPs over the care that Medicare beneficiaries receive.
    With the enactment of MMA, we are committed to providing a robust 
drug benefit to seniors, implementing responsible cost management 
provisions, as well as monitoring and improving drug therapies using 
current evidence-based guidelines. As authorized by section 109(b) of 
MMA, the QIO must offer quality improvement assistance pertaining to 
prescription drug therapy to the following:
     All Medicare providers and practitioners;
     Medicare Advantage organizations offering Medicare 
Advantage plans under Part C; and
     Organizations offering Prescription Drug Plans (PDPs) 
under Part D.
    The Part D benefit was implemented January 1, 2006. The QIOs began 
to implement quality improvement projects starting August 2006. Before 
August 2006, we identified the set of quality measures for Task 1d3 
which were derived from evidence-based guidelines and developed in 
collaboration with participating PDPs, physician societies, and other 
national leaders. The QIO will be held accountable for work with 
identified participants on clinical performance measure results.
    Because of the relatively new nature of the work, the evaluation of 
this task is more process and customer satisfaction oriented than other 
tasks in the contract. The QIO earns a conditional pass if it designs 
and completes, to CMS satisfaction, a quality improvement project 
designed to improve care with its stakeholders. The QIO will receive a 
full pass if, in addition to completing the project, 80 percent of its 
surveyed project partners report that they are satisfied with their 
work with the QIO. The QIO will earn an excellent pass if, in addition 
to the above two criteria, the project achieves improvement in the 
measures targeted by its project.

Task 2: (Reserved)

Task 3a: Beneficiary Protection
    This task involves all case review activities, including mediation, 
that are necessary to conduct statutorily mandated review of 
beneficiary complaints about the quality of health care services. It 
also involves all activities associated with other required case 
reviews, including Emergency Medical Treatment and Active Labor Act 
(EMTALA) reviews, beneficiary appeals of discharge, and fiscal 
intermediary referrals. All case review activities must be conducted in 
accordance with our instructions. Additional required activities under 
this Task are physician acknowledgment monitoring; inter-rater 
reliability (IRR) assessment; procedures based on the result of a 
review or analysis of review data; development of an Annual Report; and 
maintenance of a Medicare Helpline.
Task 3b: Hospital Payment Monitoring Program
    In the 8th SOW contract, we directed the QIOs to continue the 
Hospital Payment Monitoring Program (HPMP). The purpose of HPMP is to 
measure, monitor, and reduce the incidence of improper fee-for-service 
inpatient payments, including errors in: DRG coding; provision of 
medically necessary services; and appropriateness of setting, billing, 
and prepayment denial.
    The basis for HPMP is statutory and regulatory. Section 1154 of the 
Act statutorily mandates utilization review of professional activities 
subject to the requirements of subsection (d). In accordance with 42 
CFR 412.508(a), QIO review must include long-term acute care services. 
For FFS inpatient hospital claims (paid and denied), HPMP fulfills our 
requirement to comply with the Improper Payment Information Act of 2002 
(Pub. L. 107-300).
    The QIO will be judged successful if, at remeasurement, the 
absolute (gross total of under- and overpayments) and net (difference 
between over- and underpayments) payment error rates are

[[Page 44155]]

no greater than 1.5 standard errors above the respective absolute and 
net baseline payment error rate.
    The QIOs will also be judged in terms of timeliness of reviews. 
Monitoring activities must be summarized for payment error rates and 
hospital admission, coding, and billing patterns for short-term acute 
care inpatient FFS reimbursements in the QIO's State/jurisdiction 
including hospital profiling and trend monitoring. The QIO must submit 
its summary electronically to the Project Officer via a designated 
database as directed by CMS. Whether demonstrations of reductions in 
dollars or percent dollars paid in error and whether substantive 
knowledge are gained in the project will be determined by the Task 3b 
GTL and the QIO's Project Officer.

Task 4: Special Studies and Projects

    A Special Project is defined as work that we direct a QIO to 
perform or work that a QIO elects to perform with our approval that is 
not defined under Tasks 1-3 of the contract. The Special Project work 
must fall within the scope of the contract and of section 1154 of the 
Act. The Special Project must be conducted in accordance with contract 
sections B.4, Task 4 Special Projects; G.18, Procedures for Special 
Projects; and H.12, CMS-Directed Subcontracts/Special Project Lead 
QIOs. The term ``Special Project'' is a more accurate term for the type 
of activities and requirements characteristically implemented under 
Task 4. Other terms, previously commonly used, for activities under 
this task include ``special study'', ``special study project'', and 
``special work.''
    All Special Projects awarded/approved under Task 4 will be 
evaluated individually. The QIO's success or failure on a Special 
Project will not be factored into the evaluation of the QIO's work 
under Tasks 1-3 of the contract, except for projects funded to meet the 
requirements of Task 3b: Hospital Payment Monitoring Program. The 
assessment of performance on all other special projects under Task 4 
will affect the QIO's eligibility to receive funding for additional 
special projects under the current or subsequent QIO contracts, but 
will not affect eligibility for non-competitive renewal of the QIO 
contract. Although individual projects may include additional project-
specific assessment criteria and performance measures, every project 
awarded/approved under Task 4 is subject to evaluation on at least the 
following dimensions of performance, which apply to any and all 
projects awarded/approved under Task 4:
     Completion of specific tasks (deliverables) required in 
the special project.
     Financials.
     Appropriateness of QIO staffing for this special project 
including number of staff as well as skill sets of staff.
     Performance in meeting the needs of QIOs, other Quality 
Improvement Organization Support Centers, GTLs, etc., and the quality 
of activities to improve performance.
     Participation in other improvement activities.
     Efforts to address issues/barriers identified.
    Performance assessment for each project will be conducted jointly 
by the QIO's regularly assigned CMS Project Officer and the specific 
Special Project GTL (SPGTL).

    Authority: Section 1153 of the Social Security Act (42 U.S.C. 
1320c-2) (Catalog of Federal Domestic Assistance Program No. 93.774, 
Medicare--Supplementary Medical Insurance Program).

    Dated: March 8, 2007.
Leslie Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.

    Editorial Note: The Office of the Federal Register received this 
document on August 2, 2007.
[FR Doc. E7-15342 Filed 8-6-07; 8:45 am]
BILLING CODE 4120-01-P