For most of their history, the organizations that recover organs from the dead graded their own homework: CMS accepted OPO performance on self-reported measures that, a Senate investigation later found, were effectively unverifiable. That changed. Under a 2020 rule, CMS now grades every OPO on two objective outcome measures — a donation rate and a transplant rate — and sorts them into tiers. The grades are public, and they are damning. This is a sourced reading of that tier map, built from the data in OrganWatch.
What the tiers mean
The Conditions for Coverage rule splits OPOs into three bands each cycle. Tier 1 (top performers) is automatically recertified. Tier 2 sits above the median but must compete to keep its territory. Tier 3 — below the median on a required measure — is, in CMS's own words, out of compliance with the minimum standards to be an OPO, and is eligible for decertification, barred from competing for any other service area. Full enforcement keys to the 2026 recertification cycle.
The grades
Across the 56 OPOs with a published tier (from the 2023 OPO Interim Annual Public Aggregated Performance Report, CY2021 data), the distribution is not reassuring: 20 in Tier 3 — roughly a third of the entire national system formally below minimum standard — with 14 in Tier 2 and 22 in Tier 1. A monopoly that cannot be fired by the hospitals it serves, a third of it failing the government's own floor: that is the accountability problem in a single statistic.
The Tier 3 organizations
These 20 OPOs were placed in Tier 3 — below the median on a required outcome measure — in the CMS report. Each holds a federally granted monopoly over organ recovery in its service area:
- ARORA (Arkansas Regional Organ Recovery Agency)
- ConnectLife (Upstate New York Transplant Services)
- Donor Network of Arizona
- Finger Lakes Donor Recovery Network
- HonorBridge (formerly Carolina Donor Services)
- Kentucky Organ Donor Affiliates (KODA)
- Legacy of Life Hawaii
- Life Alliance Organ Recovery Agency (University of Miami)
- LifeGift Organ Donation Center
- LifeLink of Georgia
- LifeNet Health (organ procurement division)
- LifeQuest Organ Recovery Services (University of Florida)
- LiveOnNY
- Louisiana Organ Procurement Agency (LOPA)
- Mid-South Transplant Foundation
- Mississippi Organ Recovery Agency (MORA)
- OneLegacy
- Sierra Donor Services New Mexico (formerly New Mexico Donor Services)
- Washington Regional Transplant Community
- We Are Sharing Hope SC
The full tiered roster, each linked to the CMS report, is in the OrganWatch OPO census, which lists the worst performers first.
From grade to consequence
For years a failing grade carried no consequence. That broke in September 2025, when HHS moved to decertify the Life Alliance Organ Recovery Agency, the South Florida OPO operated within a university health system — the first decertification in the program's history. Life Alliance had sat in the lowest tier every year from 2019 through 2023; CMS selected a top-tier OPO to take over its service area of roughly seven million people. The tier map stopped being a scorecard and became, for the first time, a mechanism with teeth. It is the clearest sign that the data documented here is not academic.
What this is
Every tier here is public CMS data, source-linked in OrganWatch at the organization level. It names organizations and their government performance grades — never a patient, a donor, or a family. Naming a Tier 3 OPO is not an accusation; it is repeating the federal government's own published assessment of an organization that holds a public monopoly. That is precisely the kind of fact accountability data exists to make legible.
The data: OrganWatch — the full tiered OPO census plus the deep-investigation, prosecutions, and consent records.
Overview: OrganWatch — what the record shows. The series: the monopoly & decertification, the money, the bedside, the demand side, and the court record.