[Code of Federal Regulations]

[Title 42, Volume 4]

[Revised as of October 1, 2006]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR476.88]



[Page 472]

 

                         TITLE 42--PUBLIC HEALTH

 

  CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF 

                  HEALTH AND HUMAN SERVICES (CONTINUED)

 

PART 476_UTILIZATION AND QUALITY CONTROL REVIEW--Table of Contents

 

  Subpart C_Review Responsibilities of Utilization and Quality Control 

                Quality Improvement Organizations (QIOs)

 

Sec.  476.88  Examination of the operations and records of health care 



facilities and practitioners.



    (a) Authorization to examine records. A facility claiming Medicare 

payment must permit a QIO or its subcontractor to examine its operation 

and records (including information on charges) that are pertinent to 

health care services furnished to Medicare beneficiaries and are 

necessary for the QIO or its subcontractor to--

    (1) Perform review functions including, but not limited to--

    (i) DRG validation;

    (ii) Outlier review in facilities under a prospective payment 

system; and

    (iii) Implementation of corrective action and fraud and abuse 

prevention activities;

    (2) Evaluate cases that have been identified as deviating from the 

QIO norms and criteria, or standards; and

    (3) Evaluate the capability of the facility to perform quality 

review functions under a subcontract with the QIO.

    (b) Limitations on access to records. A QIO has access to the 

records of non-Medicare patients if--

    (1) The records relate to review performed under a non-Medicare QIO 

contract and if authorized by those patients in accordance with State 

law; or

    (2) The QIO needs the records to perform its quality review 

responsibilities under the Act and receives authorization from the 

facility or practitioner.

    (c) Conditions of examination. When examining a facility's operation 

or records the QIO must--

    (1) Examine only those operations and records (including information 

on charges) required to fulfill the purposes of paragraph (a) of this 

section;

    (2) Cooperate with agencies responsible for other examination 

functions under Federal or Federally assisted programs in order to 

minimize duplication of effort;

    (3) Conduct the examinations during reasonable hours; and

    (4) Maintain in its principal office written records of the results 

of the examination of the facility.