Saturday, July 26, 2014

Medicare Program; Evaluation Criteria and Standards for Beneficiary and Family Centered Care Quality Improvement Organization Contract

A Notice by the Centers for Medicare & Medicaid Services on 07/28/2014

This notice with comment period describes the general criteria we intend to use to evaluate the effectiveness and efficiency of Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) that will enter into contracts with CMS under the 11th Statement of Work (SOW) in May 2014 titled, “Beneficiary and Family Centered Care (BFCC) Quality Improvement Organization (QIO) Contract” (HHSM-500-2014-RFP-BFCC-QIO). This contract allows for a transition period from the incumbent QIOs to the successor QIOs. The activities for the BFCC-QIO SOW begin August 1, 2014. The evaluation of a BFCC-QIO's performance related to the SOW will be based on evaluation criteria specified for the tasks set forth in Attachment J-10 of the BFCC-QIOs' SOW contract.


Effective Date: August 1, 2014 to July 31, 2019.
Comment Date: To be assured consideration, comments must be received at one of the addresses provided below, no later than 5 p.m. on August 27, 2014.


Section 1153(h)(2) of the Social Security Act (the Act) requires the Secretary of the Department of Health and Human Services to publish in the Federal Register the general criteria and standards that will be used to evaluate the effective and efficient performance of contract obligations by the Quality Improvement Organizations (QIOs) and to provide the opportunity for public comment with respect to these criteria and standards. This notice describes the general criteria that will be used to evaluate the performance of Beneficiary and Family Centered Care (BFCC) Quality Improvement Organizations (QIOs) under the 11th Statement of Work (SOW) contract beginning August 1, 2014.

Provisions of the Notice With Comment Period

The purpose of the BFCC-QIO contract is to improve healthcare services for Medicare beneficiaries through BFCC performance of numerous statutory and regulatory review functions, including, but not limited to the following:
  • Quality of care reviews, including beneficiary complaint reviews and general quality of care reviews;
  • Beneficiary appeals of hospital discharges and terminations of service decisions, commonly referred to as Grijalva, BIPA, andWeichardt appeals.
  • Medical necessity reviews;
  • Appropriateness of setting reviews;
  • Diagnosis Related Group (DRG) reviews;
  • Readmission reviews;
  • Reviews under Emergency Medical Treatment and Active Labor Act (EMTALA);
  • Sanctions; and
  • Monitoring of Physician Acknowledgement Statements under section 1156(a) of the Act and our regulations at 42 CFR 412.46.
The BFCC-QIO contract also imposes other BFCC-QIO responsibilities: Coordinating and collaborating with other QIOs; developing and making recommendations to promote responsiveness to beneficiary and family needs; providing opportunities for listening to and addressing beneficiary and family concerns; and providing resources for beneficiaries and caregivers in decision making. These QIO beneficiary and family centered efforts align with the National Quality Strategy, which encourages patient and family engagement. (See the BFCC-QIO Statement of Work, Solicitation Number: HHSM-500-2014-RFP-BFCC-QIO, which was posted on December 5, 2013 and is available at

Evaluation of the Tasks

We will conduct monitoring activities throughout the course of the contract and will act upon findings as necessary. Information used for these monitoring purposes includes but is not limited to:Show citation box
  • Deliverables submitted by the BFCC-QIO to CMS in accordance with the Section F “Deliverables or Performance.”
  • Provider/facility surveys and/or productivity measures, including cost benefit analysis.
  • Data for measures indicated in Attachments J-4 and J-10 of the BFCC-QIO SOW.
  • Data from the BFCC-QIO's Internal Quality Control Program.
  • Other data submitted by BFCC-QIOs as required by CMS.
  • Additional information gathered by email, telephone, video or in-person visits.
BFCC-QIOs must cooperate with the Contracting Officer Representative (COR) on all our monitoring processes and address any concerns identified by the COR. We will take appropriate contract action (for example, providing warning for the need for adjustment, instituting a formal correction plan, terminating an activity, or recommending early termination of a contract because of failure to meet contract timelines or performance as specified in the contract). This means that the BFCC-QIO must comply with the Contract, Tasks, Schedules of Deliverables, Evaluation Measures Tables, and any subsequent modifications (including Health Care Quality Improvement System and Transmission of Policy Memorandums) issued by CMS.
Additionally, there will be multiple periods of more formal evaluation under this contract. The first evaluation will occur at the end of the 12th month of the contract. Subsequent evaluations will occur at the end of the 24, 36, 48 and 54th month of the contract. The evaluations will be based on the most recent data available to us. The performance results of the evaluation at each evaluation period (that is, 12, 24, 36, 48 and 54th months) will be used, in addition to ongoing monitoring activities, to determine the BFCC-QIO's performance on the overall contract.
The BFCC-QIO measures for the 11th SOW are as follows:
  • Quality of Review: Inter-Rater Reliability.
  • 4-day Data Entry Compliance.
  • Timeliness of Beneficiary Complaints and Other Quality of Care Reviews.
  • Timeliness of Discharge/Service Termination Reviews.
  • Timeliness of EMTALA and Higher Weighted Diagnosis-Related Group Reviews.
  • Complainant Agreement to Complete Survey.
  • Beneficiary Experience with Quality of Care Complaints.
  • Beneficiary Experience with Appeal Reviews.

Annual and 54th Month Evaluation

Annual and 54th month evaluation criteria are specifically defined in Attachment J-10, “Annual and 54th Month Evaluation Criteria Measures Table,” of the BFCC-QIO SOW; the criteria for evaluating each deliverable are identified in Section F (“Deliverables or Performance”) of the 11th SOW. Further, the Contracting Officer will use the Contractor Performance Assessment Reporting System (CPARS) criteria in performing evaluations: Quality, Schedule/Timeliness, Cost/Price Control, Business Relations, Management, and Small Business. Performance on the evaluation criteria defined in Attachment J-10 will be considered for assessment of the Quality sub-factor for the CPARS assessment.