[Federal Register: February 4, 2005 (Volume 70, Number 23)]
[Notices]
[Page 6012-6013]
From the Federal Register Online via GPO Access [wais.access.gpo.gov]
[DOCID:fr04fe05-92]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-3155-N]
RIN 0938-AN67
Medicare Program; Quality Improvement Organization Contracts:
Solicitation of Statements of Interest From In-State Organizations--
Alaska, Hawaii, 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, gives at least 6-months' advance notice of the expiration
dates of contracts with 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.
DATES: Written statements of interest must be received at the address
specified no later than 5 p.m. EST February 22, 2005. Due to staffing
and resource limitations, we cannot accept statements submitted by
facsimile (FAX) transmission.
ADDRESSES: Statements of interest must be submitted to the Centers for
Medicare & Medicaid Services, Acquisitions and Grants Groups, OOM,
Attn.: Carol G. Sevel, 7500 Security Boulevard, Mail Stop C2-21-15,
Baltimore, Maryland 21244-1850.
FOR FURTHER INFORMATION CONTACT: Udo Nwachukwu, (410) 786-7234.
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 Act
(Medicare) and certain other Federal programs to determine whether
those services are reasonable, medically necessary, provided in the
appropriate setting, and are of a quality that meet 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 security 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 sections 1152 and 1153 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, 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, the organization must not 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
requirements to conduct QIO Utilization and Quality Control Peer Review
as specified in Part B of Title XI of the Social Security Act and
implementing regulations.) The selected organization 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 new paragraph (i) that
prohibits us from renewing the contract of any QIO 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 the contract expires
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 submit a proposal within the specified
period of time, we cannot 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 7 QIO contracts with entities that do not meet
the statutory definition of an in-State organization. The areas
affected for purposes of this notice along with their respective
expiration dates are as follows: Vermont, July 31, 2005; Wyoming, July
31, 2005; Maine, July 31, 2005; Alaska, October 31, 2005; Idaho,
October 31, 2005; Hawaii, January 31, 2006; South Carolina, January 31,
2006.
II. Provisions of the Notice
This 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 in-State organizations may submit statements of interest
in competing to become the QIO for these States. We must receive the
statements no later than February 22, 2005, and in its statement of
interest, the organization must furnish materials 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 a subsidiary of a parent
corporation, whose headquarters 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
To be eligible as a physician-sponsored organization, the
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organization must meet the following requirements:
a. Be composed (have physicians as owners or members) of at least
20 percent of the licensed doctors of medicine and osteopathy
practicing medicine or surgery in the State (that is, at least 20
percent of the practicing physicians in the State are owners of the
QIO, or the QIO is owned by an entity which includes at least 20
percent of the practicing physicians in the State as members); or
b. Be composed (have physicians as owners or members) of at least
10 percent of the licensed doctors of medicine and osteopathy
practicing medicine or surgery in the State, and demonstrate through
means (for example, letters of support from physicians or physician
organizations) acceptable to CMS that the organization is
representative of an additional 10 percent of the practicing physicians
in the State; and
c. Not be a health care facility, health care facility association,
or health care facility affiliate.
2. Physician-Access Organization
To be eligible as a physician-access organization, the organization
must meet the following requirements:
a. Have arrangements with doctors of medicine or osteopathy,
licensed and practicing in the State, to conduct review for the
organization;
b. Have available at least one physician, licensed in the State,
from every generally recognized specialty and subspecialty who is in
active practice in the review area; and
c. Not be a health care facility, health care facility association,
or health care facility affiliate.
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 one of
the 7 QIO areas in this notice and submit statements of interest in
accordance with this notice, we will consider those organizations to be
potential sources for contract upon its 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 notice contains information collection requirements that have
been approved by the Office of Management and Budget (OMB) under the
authority of the Paperwork Reduction Act of 1995 (44 U.S.C. Chapter 35)
and assigned OMB Control Number 0938-0526 entitled ``Quality
Improvement (formerly Peer Review) Organization, Contracts:
Solicitation of Statements of Interest from In-State Organization,
General Notice and Supporting Regulations.''
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: January 26, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 05-1878 Filed 1-27-05; 5:06 pm]
BILLING CODE 4120-01-P