Peer Review Requirements

VII. Key Issues: Regulation & Reform >> B. Health Care Regulation >> Health Facilities Regulation >> Peer Review Requirements

Peer review was established as an on-going mechanism to monitor and improve quality of care for Medicare and Medicaid patients. However, in the mid-1980’s, concerns arose that the threat of private money damage liability under Federal law, especially treble damages under antitrust statutes, was unreasonably discouraging physicians from engaging in professional peer review that could improve quality of care. Peer Review Organizations (PROs) were established through the Peer Review Improvement Act of 1982. In FY2002, they were renamed Quality Improvement Organizations (QIOs). QIOs are designed to improve the quality of care for beneficiaries by ensuring that professionally recognized standards of care are met; enhance program integrity by ensuring that Medicare only pays for items that are reasonable and medically necessary; and, protect beneficiaries by addressing individual beneficiary’s complaints, hospital issued notices of non-coverage, and Emergency Medical Treatment and Labor Act (EMTALA) “dumping” violations. State QIOs carry out these responsibilities through federally funded contracts. The Duke Center for Health Policy and Inequalities Research has developed a draft working paper assessing the costs and benefits of peer review requirements, including Quality Improvement Organizations (QIOs) and the Health Care Quality Improvement Act (1986) (pdf)