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In the Medicare program, the Centers for Medicare & Medicaid Services (CMS) contracts with Quality Improvement Organizations (QIO) in each State. Pursuant to section 1862(g) of the Social Security Act, QIOs were established for the purposes of promoting the effective, efficient, and economical delivery of health care services, and of promoting the quality of services . . . . QIOs submit vouchers for Federal reimbursement to CMS monthly. The vouchers and reimbursements include amounts for both direct and indirect costs. The QIOs determine the amount of indirect costs to claim by multiplying indirect cost rates against their direct costs. During the contract period, CMS usually is unable to calculate an indirect cost rate. Therefore, QIOs use provisional rates to determine indirect costs. After the close of each QIOs fiscal year (FY), the Defense Contract Audit Agency reviews the organizations actual direct and indirect costs. The CMS contracting officer considers the Defense Contract Audit Agency's recommendations in establishing the final rate and performing the final cost settlement. The Delmarva Foundation for Medical Care (DFMC) was the Maryland QIO for the period November 1, 2002, through October 31, 2005.