[Federal Register Volume 72, Number 248 (Friday, December 28, 2007)]
[Notices]
[Pages 73842-73843]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E7-24477]



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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-3187-N]
RIN 0938-Z


Medicare Program; Quality Improvement Organization (QIO) 
Contracts: Solicitation of Proposals From In-State QIOs--Alaska, Idaho, 
Maine, South Carolina, Vermont, and Wyoming

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

ACTION: Notice.

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SUMMARY: This notice in accordance with section 1153(i) of the Social 
Security Act (the Act), gives at least 6 months advance notice of the 
expiration dates of contracts with out-of-State Quality Improvement 
Organizations (QIOs). It also specifies the period of time in which in-
State QIOs may submit a proposal for those contracts.

DATES: Interested offerors may submit a proposal to perform the QIO 
work in any of the States listed in this announcement. The Request for 
Proposal (RFP) will be made available to all interested offerors 
through the Federal Business Opportunities (http://www.fedbizopps.gov) 
Web site. CMS anticipates that the RFP for the first group of QIO 
contracts will be released sometime during the month of February 2008. 
Interested offerors should monitor the Federal Business Opportunities 
Web site for all information relating to the RFP.

ADDRESSES: Proposals for the contracts must be submitted to the Centers 
for Medicare & Medicaid Services, Acquisitions and Grants Groups, OAGM, 
Attn.: Naomi Ceresa-Haney, 7500 Security Boulevard, Mail Stop C2-21-15, 
Baltimore, Maryland 21244-1850.

FOR FURTHER INFORMATION CONTACT: Alfreda Staton, (410) 786-4194.

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 program.
    Utilization and Quality Control Peer Review Organizations, now 
known as Quality Improvement Organizations (QIOs), currently review 
certain health care services furnished under Title XVIII of the Social 
Security Act (Medicare), to determine whether those services are 
reasonable, medically necessary, provided in the appropriate setting, 
and are of a quality that meets professionally recognized standards. 
QIO activities are a part of the Health Care Quality Improvement 
Program (HCQIP), a program that supports our mission to ensure health 
care quality for our beneficiaries. The HCQIP rests on the belief that 
a plan's, provider's, or practitioner's own internal quality management 
system is key to good performance. The HCQIP is carried out locally by 
the QIO in each State. Under the HCQIP, QIOs provide critical tools 
(for example, quality indicators and information) for plans, providers, 
and practitioners to improve the quality of care provided to Medicare 
beneficiaries. The Congress created the QIO program in part to 
redirect, simplify, and enhance the cost-effectiveness and efficiency 
of the peer review process.
    In June 1984, we began awarding contracts to QIOs. We currently 
maintain 53 QIO contracts with organizations that provide medical 
review activities for the 50 States, the District of Columbia, Puerto 
Rico, and the Virgin Islands. The organizations that are eligible to 
contract as QIOs have satisfactorily demonstrated that they are either 
physician-sponsored or physician-access organizations in accordance 
with section 1152 of the Act and our regulations at 42 CFR 475.102 and 
475.103. A physician-sponsored organization is one that is both 
composed of a substantial number of the licensed doctors of medicine 
and osteopathy practicing medicine or surgery in the respective review 
area and who are 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 ensure adequate peer review of the 
services furnished by the various medical specialties and 
subspecialties. In addition, a QIO cannot be a health care facility, 
health care facility association, a health care facility affiliate, or 
in most cases a payor organization. (Statutes and regulations provide 
that, in the event CMS determines no otherwise qualified non-payor 
organization is available to undertake a given QIO contract, CMS may 
select a payor organization which otherwise meets certain requirements 
to be eligible to conduct Utilization and Quality Control Peer Review 
as specified in Part B of Title XI of the Act and its implementing 
regulations.) Section 1152(2) of the Act requires QIOs to perform 
review functions in an efficient and effective manner, and perform 
reviews of quality of care in an area of medical practice where actual 
performance is measured against objective criteria, which defines 
acceptable and adequate practice. The selected organization must have a 
consumer representative on its governing board.
    Section 1153(i) of the Act prohibits us from renewing the contract 
of any QIO that is not an in-State QIO 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 
the contract expires and must specify the period of time during which 
an in-State organization may submit a proposal for the QIO contract for 
that State. If one or more qualified in-State organizations submit a 
proposal for the QIO contract within the specified period of time, we 
cannot automatically renew the current contract on a noncompetitive 
basis, but must instead provide for competition for the contract in the 
same manner used for a new contract under section 1153(b) of the Act. 
An in-State QIO is defined at section 1153(i)(3) of the Act as a QIO 
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 6 QIO contracts with entities that do not meet 
the statutory definition of an in-State QIO. The areas affected for 
purposes of this notice along with the respective contract expiration 
dates are as follows:

Vermont July 31, 2008
Wyoming July 31, 2008
Maine July 31, 2008
Alaska October 31, 2008
Idaho October 31, 2008
South Carolina January 31, 2009

II. Provisions of the Notice

    The notice announces the scheduled expiration dates of the current 
contracts between CMS and out-of-State QIOs responsible for review in 
the areas mentioned above.
    Interested offerors may submit a proposal to perform the QIO work 
in any of the States listed in this announcement. The Request for 
Proposal (RFP) will be made available to all interested offerors 
through the Federal Business Opportunities Web site. CMS anticipates 
that the RFP for the first group of QIOs will be released

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sometime during the month of February 2008. Interested offerors should 
monitor the Federal Business Opportunities Web site for all information 
relating to the RFP.
    Section 1153(i)(3) of the Act requires that an in-State QIO have 
its primary place of business in the State in which review will be 
conducted (or, if a QIO is owned by a parent corporation, the 
headquarters of which is located in that State).
    In the proposal, each QIO must furnish, among other things, 
materials that demonstrate that it meets the following requirements 
under sections 1152(1)(A), (B), (2), and (3) of the Act and the 
regulations at Sec.  475.102 and Sec.  475.103:

A. Be Either a Physician-Sponsored or a Physician-Access Organization

1. Physician-Sponsored Organization
    To be eligible as a physician-sponsored organization, the 
organization must meet the following requirements:
    a. 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, who are representative of the physicians 
practicing in the review area.
    b. The organization must not be a health care facility, health care 
facility association, health care facility affiliate, payor 
organization, or affiliated with any of these entities. However, 
statutes and regulations provide that, in the event that we determine 
no otherwise qualified non-payor organization is available to undertake 
a given QIO contract, we may select a payor organization which 
otherwise meets requirements to be eligible to conduct Utilization and 
Quality Control Peer Review as specified in Part B of Title XI of the 
Act and its implementing regulations.
    c. In order to meet the ``substantial number of doctors of medicine 
and osteopathy'' requirement of paragraph A.1.a of this section, 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 
paragraph A.1.a of this section, 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. Alternatively, 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, 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
    To be eligible as a physician-access organization, the organization 
must meet the following requirements:
    a. 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 ensure adequate peer review of the services furnished by the 
various medical specialties and subspecialties.
    b. The organization must not be a health facility, health care 
facility association, health care facility affiliate, payor 
organization, or be affiliated with any of these mentioned entities.
    c. An organization meets the requirements of paragraph A.2.a. of 
this section 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 QIO 
area and submit proposals for the contracts in accordance with this 
notice, we will consider those organizations to be potential sources 
for the 6 contracts upon their expiration. These organizations will be 
entitled to participate in a full and open competition for the QIO 
contract to perform the QIO statement of work.

III. Information Collection Requirements

    This document does not impose information collection and 
recordkeeping requirements. Consequently, it need not be reviewed by 
the Office of Management and Budget under the authority of the 
Paperwork Reduction Act of 1995 (44 U.S.C. 35).

    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: December 6, 2007.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E7-24477 Filed 12-27-07; 8:45 am]
BILLING CODE 4120-01-P