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In the Medicare program, the Centers for Medicare & Medicaid Services (CMS) contracts with Quality Improvement Organizations (QIO) in each State. According 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 to CMS for Federal reimbursement 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 an indirect cost rate against their direct costs. During the contract period, CMS usually is unable to calculate an indirect cost rate. Therefore, the QIOs use provisional rates to determine indirect costs. After the close of each QIO's fiscal year, the Defense Contract Audit Agency (DCAA) reviews the organization's actual direct and indirect costs. The CMS contracting officer considers DCAA's recommendations in establishing the final rate and performing the final cost settlement.