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CONTRACTS WITH QUALITY IMPROVEMENT[129] ORGANIZATIONS

Sec1153[42 U.S.C. 1320c–2] (a)[130] The Secretary shall establish throughout the United States such local, State, regional, national, or other geographic areas as the Secretary determines appropriate with respect to which contracts under this part will be made.

(b)(1) The Secretary shall enter into contracts with one or more quality improvement[131] organizations[132] for each area established under subsection (a) if a qualified organization is available in such area and such organization and the Secretary have negotiated a proposed contract which the Secretary determines will be carried out by such organization in a manner consistent with the efficient and effective administration of this part. In entering into contracts with such qualified organizations, the Secretary shall, to the extent appropriate, seek to ensure that each of the functions described in section 1154(a) are carried out within an area established under subsection (a).[133] If more than one such qualified organization will be operating in an area, the Secretary shall ensure that there is no duplication of the functions carried out by such organizations within the area[134].

(2)(A) Prior to November 15, 1984, the Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), an entity (other than a self-insured employer) which directly or indirectly makes payments to any practitioner or provider whose health care services are reviewed by such entity or would be reviewed by such entity if it entered into a contract with the Secretary under this part. For purposes of this paragraph, an entity shall not be considered to be affiliated with another entity which makes payments (directly or indirectly) to any practitioner or provider, by reason of management, ownership, or common control, if the management, ownership, or common control consists only of members of the governing board being affiliated (through management, ownership, or common control) with a health maintenance organization or competitive medical plan which is an “eligible organization” as defined in section 1876(b).

(B) If, after November 14, 1984, the Secretary determines that there is no other entity available for an area with which the Secretary can enter into a contract under this part or the Secretary determines that there is a more qualified entity to perform one or more of the functions in section 1154(a)[135], the Secretary may then enter into a contract under this part with an entity described in subparagraph (A) for such area if such entity otherwise meets the requirements of this part.

(3)(A) The Secretary shall not enter into a contract under this part with any entity which is, or is affiliated with (through management, ownership, or common control), a health care facility [136] within the area served by such entity or which would be served by such entity if it entered into a contract with the Secretary under this part.

(B) For purposes of subparagraph (A), an entity shall not be considered to be affiliated with a health care facility or association of facilities by reason of management, ownership, or common control if the management, ownership, or common control consists only of not more than 20 percent of the members of the governing board of the entity being affiliated (through management, ownership, or common control) with one or more of such facilities[137].

(4)[138] The Secretary may consider a variety of factors in selecting the contractors that the Secretary determines would provide for the most efficient and effective administration of this part, such as geographic location, size, and prior experience in health care quality improvement. Quality improvement organizations operating as of January 1, 2012, shall be allowed to compete for new contracts (as determined appropriate by the Secretary) along with other qualified organizations and are eligible for renewal of contracts for terms five years thereafter (as determined appropriate by the Secretary).

(c) Each contract with an organization under this section shall provide that—

(1) the organization shall perform a function or functions under section 1154 directly or may subcontract for the performance of all or some of such function or functions[139] (and for purposes of paragraphs (2) and (3) of subsection (b), a subcontract under this paragraph shall not constitute an affiliation with the subcontractor);

(2) the Secretary shall have the right to evaluate the quality and effectiveness of the organization in carrying out the functions specified in the contract;

(3) the contract shall be for an initial term of five years[140] and shall be renewable for terms of five years[141] thereafter;

(4)[142] the Secretary shall include in the contract negotiated objectives against which the organization’s performance will be judged, and negotiated specifications for use of regional norms, or modifications thereof based on national norms, for performing review functions under the contract; and

(5)[143] reimbursement shall be made to the organization on a monthly basis, with payments for any month being made consistent with the Federal Acquisition Regulation.

In evaluating the performance of quality improvement[144] organizations under contracts under this part, the Secretary shall place emphasis on the performance of such organizations in educating providers and practitioners (particularly those in rural areas) concerning the review process and criteria being applied by the organization.

(d) [Stricken.[145]]

(e)(1) Except as provided in paragraph (2), contracting authority of the Secretary under this section may be carried out without regard to any provision of law relating to the making, performance, amendment, or modification of contracts of the United States as the Secretary may determine to be inconsistent with the purposes of this part. The Secretary may use different contracting methods with respect to different geographical areas.

(2) If a quality improvement[146] organization with a contract under this section is required to carry out a review function in addition to any function required to be carried out at the time the Secretary entered into or renewed the contract with the organization, the Secretary shall, before requiring such organization to carry out such additional function, negotiate the necessary contractual modifications, including modifications that provide for an appropriate adjustment (in light of the cost of such additional function) to the amount of reimbursement made to the organization.

(f) Any determination by the Secretary to terminate or not to renew a contract under this section shall not be subject to judicial review.

(g) The Secretary shall provide that fiscal intermediaries furnish to quality improvement[147] organizations, each month on a timely basis, data necessary to initiate the review process under section 1154(a) on a timely basis. If the Secretary determines that a fiscal intermediary is unable to furnish such data on a timely basis, the Secretary shall require the hospital to do so.

(h)(1) The Secretary shall publish in the Federal Register any new policy or procedure adopted by the Secretary that affects substantially the performance of contract obligations under this section not less than 30 days before the date on which such policy or procedure is to take effect. This paragraph shall not apply to the extent it is inconsistent with a statutory deadline.

(2) The Secretary shall publish in the Federal Register the general criteria and standards used for evaluating the efficient and effective performance of contract obligations under this section and shall provide opportunity for public comment with respect to such criteria and standards.

(3) The Secretary shall regularly furnish each quality improvement[148] organization with a contract under this section with a report that documents the performance of the organization in relation to the performance of other such organizations.

(i) [Stricken.[149]]


[129]  P.L. 112-40, §261(a)(2)(A), struck out “UTILIZATION AND QUALITY CONTROL PEER REVIEW” and inserted “QUALITY IMPROVEMENT”, applicable to contracts entered into or renewed on or after January 1, 2012

[130]  P.L. 112-40, §261(b)(1)(A), amended subsection (a) in its entirety, applicable to contracts entered into or renewed on or after January 1, 2012. For subsection (a) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 112–40.

[131]  P.L. 112-40, §261(a)(2)(C), struck out “utilization and quality control peer review” and inserted “quality improvement”, applicable to contracts entered into or renewed on or after January 1, 2012.

[132]  P.L. 112-40, §261(b)(1)(B)(i), struck out “a contract with a quality improvement organization” and inserted “contracts with one or more quality improvement organizations”, applicable to contracts entered into or renewed on or after January 1, 2012.

[133]  P.L. 112-40, §261(c)(1)(A), inserted “In entering into contracts with such qualified organizations, the Secretary shall, to the extent appropriate, seek to ensure that each of the functions described in section 1154(a) are carried out within an area established under subsection (a).”, applicable to contracts entered into or renewed on or after January 1, 2012.

[134]  P.L. 112-40, §261(b)(1)(B)(ii), struck out “meets the requirements of the preceding sentence, priority shall be given to any such organization which is described in section 1152(1)(A)”, and inserted “will be operating in an area, the Secretary shall ensure that there is no duplication of the functions carried out by such organizations within the area”, applicable to contracts entered into or renewed on or after January 1, 2012.

[135]  P.L. 112-40, §261(b)(1)(C), inserted “or the Secretary determines that there is a more qualified entity to perform one or more of the functions in section 1154(a)”, applicable to contracts entered into or renewed on or after January 1, 2012.

[136]  P.L. 112-40, §261(b)(1)(D)(i), struck out “, or association of such facilities,”, applicable to contracts entered into or renewed on or after January 1, 2012.

[137]  P.L. 112-40, §261(b)(1)(D)(ii)(II), struck out “or associations”, applicable to contracts entered into or renewed on or after January 1, 2012.

[138]  P.L. 112-40, §261(b)(3)(A), added paragraph (4), applicable to contracts entered into or renewed on or after January 1, 2012.

[139]  P.L. 112-40, §261(c)(1)(B), struck out “the functions set forth in section 1154(a), or may subcontract for the performance of all or some of such functions” and inserted “a function or functions under section 1154 directly or may subcontract for the performance of all or some of such function or functions”, applicable to contracts entered into or renewed on or after January 1, 2012.

[140]  P.L. 112-40, §261(b)(2)(A), struck out “three years” and inserted “five years”, applicable to contracts entered into or renewed on or after January 1, 2012.

[141]  P.L. 112-40, §261(b)(2)(B), struck out “on a triennial basis” and inserted “for terms of five years”, applicable to contracts entered into or renewed on or after January 1, 2012.

[142]  P.L. 112-40, §261(b)(3)(B), struck out former paragraphs (4) through (6) and redesignated paragraphs (7) and (8) as paragraphs (4) and (5), respectively, applicable to contracts entered into or renewed on or after January 1, 2012. For the former paragraphs (4) through (6) as they formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 112-40.

[143]  P.L. 112-40, §261(b), amended this paragraph (5), as so redesignated by §261(b)(3)(B), in its entirety, applicable to contracts on or after January 1, 2012. For this paragraph (5) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 112-40.

[144]  P.L. 112-40, §261(a)(2)(C), struck out “utilization and quality control peer review” and inserted “quality improvement”, applicable to contracts entered into or renewed on or after January 1, 2012.

[145]  P.L. 112-40, §261(b)(3)(C), struck out subsection (d), applicable to contracts entered into or renewed on or after January 1, 2012. For subsection (d) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 112-40.

[146]  P.L. 112-40, §261(a)(2)(C), struck out “peer review” and inserted “quality improvement”, applicable to contracts entered into or renewed on or after January 1, 2012.

[147]  P.L. 112-40, §261(a)(2)(C), struck out “peer review” and inserted “quality improvement”, applicable to contracts entered into or renewed on or after January 1, 2012.

[148]  P.L. 112-40, §261(a)(2)(C), struck out “utilization and quality control peer review” and inserted “quality improvement”, applicable to contracts entered into or renewed on or after January 1, 2012.

[149]  P.L. 112-40, §261(b)(1)(E), struck out subsection (i), applicable to contracts entered into or renewed on or after January 1, 2012. For subsection (i) as it formerly read, see Vol. II, Appendix J, Superseded Provisions, P.L. 112–40.