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Quality Improvement Organization Changes Affect Medicare Case Review

New Regional Contractors Named; Transitions Underway

The Centers for Medicare & Medicaid Services (CMS) has restructured the existing Quality Improvement Organization (QIO) program, in which each QIO performs both case review and quality improvement support for each state or territory, to a regional structure for case review and an industry-determined service structure for quality improvement initiatives. 

In the new structure, case review and quality improvement functions will be performed by different contractors. Beneficiary and Family Centered Care (BFCC) QIOs will now perform all beneficiary complaint and clinical reviews. Quality Innovation Network (QIN) QIOs will be responsible for working with providers and the community on multiple data-driven quality initiatives to improve safety, reduce harm and improve clinical care at their local and regional levels.

BFCC regional mapOn May 9, 2014, CMS launched the first phase of the QIO transition by awarding BFCC-QIO responsibilities to two organizations. Livanta, LLC, located in Annapolis, Maryland, was awarded BFCC-QIO functions for areas 1 and 5 and KEPRO, located in Seven Hills Ohio, was awarded areas 2, 3 and 4. Please refer to the attached BFCC-QIO regional map regarding the states/territories covered in each area. All future beneficiary quality review case work, including appeals, will be conducted by the BFCC-QIO effective August 1, 2014.