Medicare Compliance & Reimbursement

Health care providers should be aware that patients will now be able to extract potentially damaging information from QIOs.

If a patient ever complains to a quality improvement organization, the Medicare QIO must tell her, at a minimum, whether the QIO believes the beneficiary's treatment met "professionally recognized standards of health care," the U.S. Court of Appeals for the D.C. Circuit ruled June 23 in Public Citizen Inc. v. Dep't of Health and Human Services (No. 01-5294).

The appellate panel was construing a provision of the Social Security Act stating that a QIO - previously known as a peer review organization - "shall inform the individual (or representative) of the organization's final disposition of the complaint." Following the Centers for Medicare & Medicaid Services manual, QIOs currently tell beneficiaries only that their complaint has been received and examined and that the QIO will take unspecified appropriate action if warranted.