CMS Audits Home Health Agencies
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.
In the CY 2015 Home Health Final Rule (available in Related Links section below), CMS proposed to establish a new “Pay-for-Reporting Performance Requirement” with which provider compliance with quality reporting program requirements can be measured. This proposal was made for several reasons.
First, we believe that defining a more explicit performance requirement for the submission of OASIS data by HHAs would better meet section 5201(c)(2) of the Deficit Reduction Act of 2005 (DRA), which requires that “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.”
Second, in February 2012, the Department of Health & Human Services Office of the Inspector General (OIG) performed a study to: (1) Determine the extent to which home health agencies (HHAs) meet Federal reporting requirements for the Outcome and Assessment Information Set (OASIS) data; (2) to determine the extent to which states meet federal reporting requirements for OASIS data; and (3) to determine the extent to which the Centers for Medicare & Medicaid Services (CMS) oversees the accuracy and completeness of OASIS data submitted by HHAs. In a report entitled, “Limited Oversight of Home Health Agency OASIS Data” (available in the Download section below) the OIG made a finding that “CMS did not ensure the accuracy or completeness of OASIS data.” The OIG recommended that CMS “identify all HHAs that failed to submit OASIS data and apply the 2-percent payment reduction to them.” We believe that establishing a performance requirement for submission of OASIS quality data would be responsive to the recommendations of the OIG.
This performance system is driven by the principle that each HHA will be expected to submit a minimum set of two “matching” assessments for each patient admitted to their agency. These matching assessments together create what is considered a “quality episode of care”, which would ideally consist of a Start of Care (SOC) or Resumption of Care (ROC) assessment and a matching End of Care (EOC) assessment. However, there are several scenarios that could meet this “matching assessment requirement” of the new pay-for-reporting performance requirement. These scenarios have been defined as “quality assessments” which are defined as assessments that create a quality episode of care during the reporting period or could create a quality episode if the reporting period were expanded to an earlier reporting period or into the next reporting period. Seven types of OASIS assessments submitted by an HHA will fit this definition of a quality assessment. The seven OASIS assessments are:
- A Start of Care (SOC) or Resumption of Care (ROC) assessment that has a matching End of Care (EOC) assessment. EOC assessments are assessments that are conducted at transfer to an inpatient facility (with or without discharge), death, or discharge from home health care. These two assessments (the SOC or ROC assessment and the EOC assessment) create a regular quality episode of care and both count as quality assessments.
- An SOC/ROC assessment that could begin an episode of care, but occurs in the last 60 days of the performance period. This is labeled as a “Late SOC/ROC” quality assessment.
- An EOC assessment that could end an episode of care that began in the previous reporting period, (that is, an EOC that occurs in the first 60 days of the performance period.) This is labeled as an “Early EOC” quality assessment.
- An SOC/ROC assessment that is followed by one or more follow-up assessments, the last of which occurs in the last 60 days of the performance period. This is labeled as an “SOC/ROC Pseudo Episode” quality assessment.
- An EOC assessment is preceded by one or more Follow-up assessments, the last of which occurs in the first 60 days of the performance period. This is labeled an “EOC Pseudo Episode” quality assessment.
- An SOC/ROC assessment that is part of a known one-visit episode. This is labeled as a “One-visit episode” quality assessment.
- SOC, ROC, and EOC assessments that do not meet any of these definitions are labeled as “Non-Quality” assessments.
- Follow-up assessments (that is, where the M0100 Reason for Assessment = ‘04’ or ‘05’) are considered “Neutral” assessments and do not count toward or against the pay for reporting performance requirement.
Compliance with the pay-for-reporting performance requirement can be measured through the use of an uncomplicated mathematical formula. We have titled this formula as the “Quality Assessments Only” (QAO) formula because only those OASIS assessments that contribute, or could contribute, to creating a quality episode of care are included in the computation. The formula based on this definition is as follows:
QAO = # Quality Assessments x 100
# Quality Assessments + # Non-Quality Assessments
Our ultimate goal is to require all HHAs to achieve a quality reporting compliance rate of 90 percent or more, as calculated using the QAO metric illustrated above. We intend to implement this performance requirement in an incremental fashion over a 3 year period beginning with all episodes of care that occur on or after July 1, 2015, in accordance with the following schedule:
- For episodes beginning on or after July 1st, 2015 and before June 30th, 2016, HHAs must score at least 70 percent on the QAO metric of pay-for-reporting performance or be subject to a 2 percentage point reduction to their market basket update for CY 2017.
- For episodes beginning on or after July 1st, 2016 and before June 30th 2017, HHAs must score at least 80 percent on the QAO metric of pay-for-reporting performance or be subject to a 2 percentage point reduction to their market basket update for CY 2018.
- For episodes begging on or after July 1st, 2017 and thereafter, the required performance levels HHAs must score at least 90 percent on the QAO metric of pay-for-reporting performance or be subject to a 2 percentage point reduction to their market basket update for CY 2019 and thereafter.
CMS Audits Home Health Agencies