Government’s new QIO contractors are not working out, hospital groups say

Putting hospital staff seeking to file an appeal request on hold for six hours, no secure way file to documentation electronically, lost paperwork, taking 10 days to issue a discharge appeal decision and other serious customer service issues have led the American Hospital Association (AHA) and the Federation of American Hospitals (FAH) to conclude that the transition to the new national Quality Improvement Organization (QIO) program contractors for Beneficiary and Family Centered Care is “not working as it should.”

In a letter to the Centers for Medicare & Medicaid Services (CMS), the hospital groups listed a range of problems that were impacting their member organizations and Medicare beneficiaries. The latter had in some cases been told that they were responsible for multiple full days of hospital care because their extended hospital stay was not approved — a frightening situation for many retired seniors on fixed incomes.

“All of these challenges directly impact patients’ health and financial well-being, as well as hospitals’ ability to efficiently manage the provision of care,” the AHA and FAH wrote.

Other issues identified included the Beneficiary and Family Centered Care reviewing physicians being “overwhelmed with the volume of requests and charts,” a complete reliance on time-consuming fax and phone communication because the companies that had won the QIO contract did not have secure ways to transmit information electronically, Beneficiary and Family Centered Care decisions accidentally being sent to patients instead of hospitals or to the wrong hospital, and conflicting information being given to patients and hospitals.

Two privately-held government contractors handle all the Beneficiary and Family Centered Care QIO program management for CMS. They are Annapolis Junction, Maryland-based Livanta LLC and Harrisburg, Pennsylvania-based KEPRO. Both won their respective 5-year government contracts in May. Livanta is responsible for the program management in the Northeast states of Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont; the Western states of Arizona, California, Idaho, Nevada, Oregon and Washington; as well as Alaska, Hawaii and the territories of Puerto Rico and the U.S. Virgin Islands. KEPRO is responsible for the rest of the United States.

The QIO program is one of the largest federal programs dedicated to improving health quality for Medicare beneficiaries. By law, it is supposed to improve the effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries. According to how CMS defines this work, the QIO contractors are also supposed to protect the integrity of the Medicare Trust Fund by ensuring that Medicare pays only for services and goods that are reasonable and necessary and that are provided in the most appropriate setting. In addition, the The Beneficiary and Family Centered Care QIOs are supposed to ensure “consistency in the case review process while taking into consideration local factors and local needs for general quality of care, medical necessity, and readmissions.”

In the letter, the AHA and FAH said they wanted to work with CMS to help make the transition smoother, but they also wanted CMS to issue guidance on the best way to protect patients and their member organizations from possible harm due to the current problems with the transition to the new contractors.