In 1982, Congress established Utilization and Quality Control Peer Review Organizations (PROs) (now known as QIN – QIOs) to perform two broad functions:
promote quality health care services for Medicare beneficiaries, and
determine whether services rendered are medically necessary, appropriate and meet professionally recognized standards of care.
CMS also contracts with QIOs to validate provider-coding assignments, which affect reimbursement. The goal of the QIN – QIO program is to improve the processes and outcomes of care for Medicare beneficiaries. The QIN – QIO is to achieve this goal through performance of various directives promulgated by CMS in the QIN – QIO Contract, as discussed below.
GMCF is the QIN – QIO in Georgia doing the (a) section of this work as outlined above.
KEPRO is now the QIN – QIO in Georgia doing the (b) section outlined above.
Purpose of Agreement with KEPRO
The purpose of this Agreement is to define the administrative relationship that will exist between parties in the exchange of data and information. This Memorandum of Agreement is required by the Medicare statute and regulations as well as the QIO Manual and certain QIO contract directives. It is also intended to be informational. The QIO wants to inform Georgia hospitals, home health agencies, skilled nursing facilities, Medicare Advantage organizations, critical access hospital, […]