Determining Provider Compliance with Home Health Quality Reporting Program Requirements
Section 1895(b)(3)(B)(v)(I) of the Act states that:
“For 2007 and each subsequent year, in the case of a home health agency that does not submit data to the Secretary in accordance with subclause (II) with respect to such a year, the home health market basket percentage increase applicable under such clause for such year shall be reduced by 2 percentage points.”
This “pay-for-reporting” requirement was implemented on January 1, 2007. However, to date, the quantity of OASIS assessments each HHA must submit to meet this requirement has never been proposed and finalized through rulemaking or through the sub-regulatory process.
The 2015 CMS Proposal: Establishing a Pay-for-Reporting Performance Requirement
In the CY 2015 Home Health Final Rule, CMS proposed a new “Pay-for-Reporting Performance Requirement” to better evaluate provider compliance with quality reporting program requirements. This proposal was introduced for several reasons:
Alignment with the Deficit Reduction Act of 2005
CMS aimed to better meet Section 5201(c)(2) of the DRA, which mandates:
“Each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality. Such data shall be submitted in a form and manner, and at a time, specified by the Secretary for purposes of this clause.”
OIG’s 2012 Findings on OASIS Data Oversight
In February 2012, the Department of Health & Human Services Office of the Inspector General (OIG) conducted a study to:
- Determine the extent to which HHAs meet Federal reporting requirements for OASIS data.
- Determine the extent to which states meet federal reporting requirements for OASIS data.
- Determine the extent to which CMS oversees the accuracy and completeness of OASIS data submitted by HHAs.
In a report titled “Limited Oversight of Home Health Agency OASIS Data”, the OIG found that:
“CMS did not ensure the accuracy or completeness of OASIS data.”
The OIG recommended:
“Identify all HHAs that failed to submit OASIS data and apply the 2-percent payment reduction to them.”
CMS believes establishing a performance requirement for OASIS data submission would directly respond to the OIG’s recommendations.
Definition of Quality Assessments and Episode Scenarios
CMS defined a performance system where each HHA must submit at least two “matching” assessments for each patient admitted. These assessments form a “quality episode of care” and typically consist of:
- A Start of Care (SOC) or Resumption of Care (ROC) assessment
- A matching End of Care (EOC) assessment
Several scenarios are recognized as meeting the “matching assessment requirement”:
The Seven Types of Quality Assessments
- SOC or ROC + Matching EOC
A standard episode that begins with an SOC/ROC and ends with an EOC (e.g., discharge, transfer, or death). - Late SOC/ROC
SOC/ROC assessments that begin an episode within the last 60 days of the performance period. - Early EOC
EOC assessments that complete episodes started in the previous reporting period but end in the first 60 days of the current period. - SOC/ROC Pseudo Episode
SOC/ROC followed by follow-up assessments, with the last follow-up in the final 60 days of the performance period. - EOC Pseudo Episode
EOC preceded by follow-up assessments, with the last follow-up in the first 60 days of the period. - One-Visit Episode
A known one-visit case with only an SOC/ROC. - Non-Quality Assessments
SOC, ROC, or EOC assessments not matching any of the above definitions.
Follow-up assessments (M0100 Reason for Assessment = ‘04’ or ‘05’) are deemed “Neutral” and neither count for nor against the compliance requirement.
The QAO Formula for Measuring Compliance
CMS introduced the “Quality Assessments Only” (QAO) formula to quantify compliance:
QAO =
(# Quality Assessments × 100) / (# Quality Assessments + # Non-Quality Assessments)
The goal is to reach a compliance rate of 90% or more using this metric.
Phased Implementation Timeline
CMS is implementing the performance requirement over a 3-year period starting July 1, 2015, with increasing thresholds:
- July 1, 2015 – June 30, 2016
- Minimum score: 70%
- Penalty: 2% market basket reduction for CY 2017
- July 1, 2016 – June 30, 2017
- Minimum score: 80%
- Penalty: 2% market basket reduction for CY 2018
- On or after July 1, 2017
- Minimum score: 90%
- Penalty: 2% market basket reduction for CY 2019 and beyond
Frequently Asked Questions
What is the Home Health Quality Reporting Program (HHQRP) compliance requirement?
The HHQRP compliance requirement mandates that home health agencies (HHAs) submit sufficient OASIS data to avoid a 2% reduction in their market basket update. This “pay-for-reporting” policy has been in effect since 2007, with updated performance criteria phased in beginning in 2015.
What does the “Quality Assessments Only” (QAO) formula measure?
The QAO formula measures the proportion of quality assessments submitted by an HHA versus total assessments. It is calculated as:
QAO = (Quality Assessments × 100) / (Quality + Non-Quality Assessments)
A 90% or higher score is required to avoid a penalty starting from July 1, 2017.
What types of assessments are considered “quality assessments”?
Quality assessments include Start of Care (SOC) or Resumption of Care (ROC) assessments that match with an End of Care (EOC) assessment. Several variations are recognized, such as late SOC/ROC, early EOC, and one-visit episodes.
What are “non-quality assessments” and how do they affect compliance?
Non-quality assessments are SOC, ROC, or EOC assessments that don’t match the defined quality episode types. These negatively affect an HHA’s QAO score, potentially leading to a market basket reduction if the compliance threshold isn’t met.
How is the compliance threshold changing over time?
CMS introduced a phased threshold increase over three years starting in 2015. The minimum QAO compliance rate was 70% for 2016, 80% for 2017, and 90% from 2018 onward. Falling below the threshold results in a 2% payment reduction.