QIOs: A National Resource for External Review of Grievances and Appeals The Social Security Act requires QIOs to review beneficiary complaints asserting that the medical necessity and quality of services does not meet professionally recognized standards of health care. QIOs also contract with individual states and health plans to provide independent external review services. Medicare Beneficiary Protection The beneficiary or their representative may file a complaint with a QIO. Referrals also come from HCFA, fiscal intermediaries, carriers, and the Office of Inspector General (OIG). In 1998, QIOs conducted an estimated 14,000 Medicare reviews to evaluate the quality or necessity of care. QIOs can conduct a case review of a beneficiary’s medical care provided in any setting except the physician’s office. (If the beneficiary is in an HMO, the physician office records are open to review.) Each QIO has direct access to physician specialists throughout each community. QIOs provide an impartial third party evaluation of the care provided. An Example of a Beneficiary Complaint Prostate Surgery -- A physician was reportedly performing unnecessary removals of prostate glands and testicles. Through profiling and case review, the QIO determined the medical care documented did not meet professionally recognized standards. The QIO placed the physician on a corrective action plan that required consultations and approvals before performing any non-emergency procedures. External Review of Health Plan Decisions 18 states currently have an independent external review law. QIOs perform reviews in CT, MO, NY, NJ, RI, TX, MD,VA. In 4 states, QIOs are the only entity used for external review. Since 1994, QIOs have performed over 1,200 combined reviews. Impact, Scope and Cost 16 States require that the external reviewer’s decision be binding on the plan. On average, external reviewers uphold as many health plan decisions as they overturn. A standard review takes 30 days, expedited review is 72 hours. In most states, one review costs less than $500. Generally, the health plan pays for the review; however, there are states that pay, and one state does split the cost between the plan and the consumer. Sources: PRO Results: Bridging the Past with the Future, Department of Health and Human Services, Health Care Financing Administration, Office of Clinical Standards and Quality, September 1998. External Review of Health Plan Decisions: An Overview of Key Program Features in the States and Medicare, The Henry J. Kaiser Family Foundation, Karen Pollitz, MPP, Geraldine Dallek, MPH, Nicole Tapay, JD, Institute for Health Care Research and Policy Georgetown University, November 1998.