Page:United States Statutes at Large Volume 100 Part 3.djvu/237

 PUBLIC LAW 99-509—OCT. 21, 1986

100 STAT. 2045

(1) ALLOCATION OF FUNDS FOR QUALITY CARE REVIEW.—Section

1154(a)(4) of the Social Security Act (42 U.S.C. 1320c-3(a)(4)) is amended by adding at the end the following: "Each peer review organization shall provide that a reasonable proportion of its activities are involved with reviewing, under paragraph (1)(B), the quality of services and that a reasonable allocation of such activities is made among the different cases and settings (including post-acute-care settings, ambulatory settings, and health maintenance organizations). In establishing such allocation, the organization shall consider (i) whether there is reason to believe that there is a particular need for reviews of particular cases or settings because of previous problems regarding quality of care, (ii) the cost of such reviews and the likely yield of such reviews in terms of number and seriousness of quality of care problems likely to be discovered as a result of such reviews, and (iii) the availability and adequacy of alternative quality review and assurance mechanisms.".

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(2) REQUIRING REVIEW OF HEALTH MAINTENANCE ORGANIZA-

TIONS AND COMPETITIVE MEDICAL PLANS.—Such section is further amended— (A) by inserting "(A)" after "(4)"; (B) by adding at the end the following new subparagraph: "(B) The contract of each organization shall provide for the review of services (including both inpatient and outpatient services) provided by eligible organizations pursuant to a contract under section 1876 for the purpose of determining whether the quality of such services meets professionally recognized standards of health care, including whether appropriate health care services have not been provided or have been provided in inappropriate settings. The previous sentence shall not apply with respect to a contract year if another entity has been awarded a contract under subparagraph (C)."; (C) by adding at the end of such subparagraph the following: "Under the contract the level of effort expended by the Oi u v organization on reviews under this subparagraph shall be equivalent, on a per enrollee basis, to the level of effort expended by the organization on utilization and quality reviews performed with respect to individuals not enrolled with an eligible organization."; and (D) by adding at the end the following additional new subparagraph: "(C) The Secretary may provide, by contract under competitive procurement procedures on a State-by-State basis in up to 25 States, for the review described in subparagraph (B) by an appropriate entity (which may be a peer review organization described in that subparagraph). In selecting among States in which to conduct such competitive procurement procedures, the Secretary may not select States which, as a group, have more than 50 percent of the total number of individuals enrolled with eligible organizations under section 1876. Under a contract with an entity under this subparagraph— "(i) the entity must be, or must meet all the requirements under section 1152 to be, a utilization and quality control peer review organization, "(ii) the contract must meet the requirement of section 1153(b)(3), and

Contracts.

42 USC 1395inm.

Contracts, , >

Contracts. State and local governments.

42 USC 1320c-l. 42 USC l320c-2.

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