CMS Quality Improvement Organizations (QIO) Information Systems
Investment ID: 009-000348476
Overview
Program Title
CMS Quality Improvement Organizations (QIO) Information Systems
Description
The Peer Review Improvement Act of 1982 amended Part B of title XI of the Social Security Act (the Act) by establishing the Utilization and Quality Control Peer Review Organization program, now known as the Quality Improvement Organizations (QIOs). The program is administered under the Health and Human Services department of the Centers for Medicare & Medicaid Services. The PRO program was established in order to redirect, simplify, and enhance the cost-effectiveness and efficiency of the medical peer review process.
QIOs and other QIO related contractors are responsible for submitting deliverables in order for CMS to verify and validation the contractors are performing their required duties as specified in their respective Scopes of Work.
Type of Program
Major IT Investments
Multi-Agency Category
Not Applicable
Associated Websites
https://fivsng.cms.gov/, https://darrt.cms.gov/, https://qmars.cms.gov
Investment Detail
This investment is a legislatively mandated quality program where participating providers submit data to CMS. CMS uses this data to assist consumers in making more informed decisions about their health care and improve the quality of care within the targeted care settings. Through supporting legislation, CMS can make positive and negative adjustments to payment rates based on approved quality measures. ROI for this quality program is routinely calculated by the Agencies Actuarial services team as part of the budgetary process supporting this program. This is done to ensure this program investment aligns to the Agency and Departmental goals to improve healthcare and health at a lower cost, i.e. value based care . The goal of this investment is to aid CMS in gathering real time data related to Quality Improvement or case reviews to be able to quickly adjust direction to the QIOs to provide support where needed. For QMARS in particular this investment is integral and benefits the BFCC Program in a multitude of ways, most specifically ensuring that the beneficiary complaint processes are efficient, functional, secure, and well documented in the provision of timely, fair service in support of both beneficiaries and health providers. It is expected that for the 12th SoW the QIOs will process over 1 million case reviews, 70% of which will be expedited appeals cases and QMARS will support this process. For DARRT this measure the return on investment, quality improvement processe and progress as well as allowing for the assessment of Quality Improvement Initiatives (QII) reported raw data, trends, tracking progress per provider, state, region and per QIN. DARRT works toward CMS' goal of improving infection control rates and practices nationwide for our Medicare Beneficiaries.