Centers for Medicare and Medicaid Services (CMS)

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The Centers for Medicare and Medicaid Services (CMS) is a branch of the U.S. Department of Health and Human Services [1]. The CMS is the federal agency which is responsible for clinical decision support (CDS) initiatives, administrative simplification standards from Health Insurance Portability and Accountability Act (HIPAA), and quality standards in healthcare facilities through its survey and certification activity.


The CMS administers the Medicare, Medicaid, and the Children's Health Insurance Program.


Doctors' Office Quality Information Technology (DOQ-IT)]

A special study to develop an approach to promoting adoption and use of information technologies in the physician office and reporting of information to Quality Improvement Organizations (QIOs). [2]

VistA Office EHR

Modify / repackage VistA (the Veteran's Administration EHR software) for the physician office setting.

Medicare Care Management Performance Demonstration Establish a three-year, pay-for-performance pilot with physicians to promote the adoption and effective use of HIT to improve the quality of patient care for chronically ill Medicare patients. CMS will offer financial incentives to physician offices that meet performance standards in delivery systems and outcomes.

Medicare Health Care Quality Demonstration Program

Section 646 of the Medicare Modernization Act (MMA) mandates a 5-year demonstration program under which CMS will test major changes to improve quality of care while increasing efficiency across an entire health care system. The Demonstration recognizes the use of health IT to improve quality.

Physician self-referral exception: Phase II of physician self-referral regulations includes exception for community-wide health information systems

Removes the regulatory barrier to allow for the furnishing of technology items or services to physicians to enable their participation in community-wide health information systems.

E-prescribing hearings to develop, adopt, recognize, or modify initial e-prescribing standards. Pilot project to test initial standards

Participate in NCVHS hearings regarding e-prescribing standards in 2004 and 2005. Develop, adopt, recognize, or modify initial uniform standards not later than Sept. 1, 2005. During 2006 calendar year, conduct pilot project to test initial e-prescribing standards, unless the Secretary determines the industry has adequate experience with such standards. [3]

EMR Focus Groups

Pacific Consulting Group, under contract with CMS, will conduct 12 focus groups of providers to identify the issues and barriers that would prevent them from using electronic medical records, and suggestions they may have for addressing these issues. The focus groups will be organized as follows: three Part A, three Part B, three durable medical equipment (DME) providers, two rural providers, and one billing agent. Six of these focus groups will be in person, while six will meet via conference call. Focus groups are planned for the following cities: Boston or New York City, Florida or Atlanta, Chicago, Denver, San Francisco.

CMS Virtual Call Center

The goal of CM' Virtual Call Center is to improve beneficiary telephone customer service through the implementation of various initiatives for efficient and effective handling of all types of inquiries. The first phase involves, among other things, improvements in the Web-based application that allows phone representatives to retrieve clinical information about the beneficiary (such as date of last pap smear or colonoscopy). The second phase involves allowing beneficiaries to access clinical information about themselves through a Web-based application.


Quality Improvement Organization (QIO)

Created by statute in 1982 to improve the quality and efficiency of healthcare services delivered to Medicare beneficiaries, the QIO Program is viewed by CMS as an integral part of its efforts to improve quality. [4]

The QIO Program is one of the largest federal programs dedicated to improving healthcare quality for Medicare beneficiaries. QIOs are made up of health quality experts, clinicians, and consumers to achieve the core functions of the Program:

  • Improving quality of care for beneficiaries
  • Protecting 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
  • Protecting beneficiaries by expeditiously addressing individual complaints, such as beneficiary complaints; provider-based notice appeals; violations of the Emergency Medical Treatment and Labor Act (EMTALA); and other related responsibilities as articulated in QIO-related law. [5]

In 2013 the QIO Program was redesigned, and case review was separated from quality improvement. Additionally, the contract periods were extended from three years to five years.

Beneficiary and Family Centered Care (BFCC)-QIOs

BFCC-QIOs perform case review to ensure Medicare beneficiaries are receiving quality care that is medically necessary. This is done through expeditious statutory review functions, including complaint and quality of care reviews.

Quality Innovation Network (QIN)-QIOs

QIN-QIOs improve healthcare quality through education, outreach, sharing practices that have worked in other areas, using data to measure improvement, working with patients and families and convening community partners for communication and collaboration. [6]

QIO section added by Jennifer Wright --Wrijenn (talk) 20:48, 26 April 2015 (PDT)