A QIO, or Quality Improvement Organization, is a federally funded group of health quality experts that works to improve the care Medicare beneficiaries receive. Established under the Social Security Act, QIOs serve two core functions: they help individual Medicare patients resolve complaints about their care, and they work directly with hospitals, nursing homes, and physician offices to raise the overall standard of care nationwide.
How QIOs Are Structured
The QIO program is managed by the Centers for Medicare & Medicaid Services (CMS) and split into two distinct types of organizations, each with a different job.
Beneficiary and Family Centered Care QIOs (BFCC-QIOs) are the patient-facing side. They handle quality-of-care complaints from Medicare beneficiaries, review medical records when something may have gone wrong, and manage fast appeals when a hospital or facility tries to end your Medicare-covered services. The two current BFCC-QIOs are Acentra Health (formerly Kepro) and Commence Health (formerly Livanta), operating under contracts that run from May 2024 through April 2029.
Quality Innovation Network QIOs (QIN-QIOs) focus on systemic improvement. Seven QIN-QIOs work directly with healthcare providers, helping hospitals coordinate post-discharge care, making nursing home stays safer, and promoting digital health tools to reduce patient harm. Their current contracts run from May 2025 through May 2030.
What QIOs Are Legally Required to Do
Under Section 1154 of the Social Security Act, QIOs have three core responsibilities when reviewing care paid for by Medicare. First, they determine whether services were reasonable and medically necessary. Second, they evaluate whether the quality of care met professionally recognized standards. Third, they assess whether inpatient care could have been provided just as effectively in a less costly setting, like an outpatient clinic or a different type of facility. Based on these reviews, a QIO can determine whether Medicare should pay for the services in question.
Filing a Quality-of-Care Complaint
If you’re a Medicare beneficiary and you believe you received substandard care, you can file a complaint with your regional BFCC-QIO. The process works like this: once the QIO receives your complaint, it requests all relevant medical records from the provider. That provider has 14 calendar days to turn them over, though the QIO can demand them sooner if it suspects a serious quality concern.
A peer reviewer then evaluates the records using evidence-based standards of care. If no established standard exists for your situation, the reviewer relies on best practices and clinical guidelines. The review focuses specifically on the episode of care your complaint addresses, though the QIO may flag additional concerns it identifies. Within 10 calendar days of receiving all the medical information, the peer reviewer completes the review and notifies the provider of an initial determination.
If the reviewer finds that care fell below professional standards, the provider gets a phone call and has 7 calendar days to discuss the finding with the QIO. All information gathered during the review is held confidential. You can submit any supporting materials you have, and the QIO will consider them alongside the medical records.
Fast Appeals for Discharge Decisions
One of the most time-sensitive things a QIO does is handle fast appeals when a hospital or facility says your Medicare-covered services are ending. If you’re in a hospital and disagree with a discharge decision, you can request an expedited review by following the directions on the “Important Message from Medicare” form, which you should receive no later than the day you’re scheduled to leave. In other settings like skilled nursing facilities or home health, you need to contact the BFCC-QIO by noon the day before the listed termination date, following the instructions on the “Notice of Medicare Non-Coverage.”
The turnaround is fast by design. For hospital appeals, the BFCC-QIO issues a decision within one day of getting the information it needs. For appeals in other care settings, the decision comes by close of business the day after the QIO receives the necessary information. While the appeal is being reviewed, you generally cannot be charged for the disputed services.
How QIN-QIOs Improve Care at the System Level
While BFCC-QIOs respond to individual patient concerns, QIN-QIOs take a broader approach. They partner with healthcare facilities to tackle patterns that affect large numbers of patients. Their current priorities include coordinating care after hospital stays to prevent avoidable readmissions, improving safety in hospitals and nursing homes, and helping providers adopt digital health tools that reduce errors and other forms of patient harm.
These organizations work on the ground with clinical staff, offering training, data analysis, and technical support. The goal is not to penalize providers but to identify where systems break down and help fix them. A QIN-QIO might, for example, help a nursing home redesign its medication management process or coach a hospital on better handoff communication between shifts.
How to Contact a QIO
Every state is covered by both a BFCC-QIO and a QIN-QIO. To find yours, you can call 1-800-MEDICARE (1-800-633-4227) or visit the CMS website and search for Quality Improvement Organizations. If you’re currently in a hospital or facility and need to file a fast appeal, the contact information for your BFCC-QIO will be listed on the discharge notice you receive. You don’t need a lawyer or an advocate to file a complaint or appeal, and there’s no cost to you for the review.