HCFA publishes OASIS rules with no concessions

By MATTHEW HAY

HHBR Washington Correspondent

WASHINGTON — The Health Care Financing Administration (HCFA; Baltimore) last week published a final rule that will require agencies to begin using the Outcome and Assessment Information Set (OASIS) for comprehensive assessment. The regulations are being published in two parts, according to HCFA. The final rule includes only that portion of the proposed home health conditions of participation relating to comprehensive assessment and collecting OASIS as part of the assessment. An interim final rule was also published that will require agencies to report OASIS data electronically as a condition of participation. Under these rules, home health agencies are required to begin collecting OASIS data by Feb. 24, 1999, and transmitting these data by April 26, 1999. A final section of the OASIS regulations yet to be published will address how the data is to be transmitted to HCFA.

There is no comment period for this final regulation, however, home health agencies and others are allowed to make cost "impact" comments within 15 days, and they are being urged to do so by industry representatives. The interim final rule has a 60-day comment period that ends March 26, 1999.

The OASIS data set is a set of standardized questions designed to reflect key characteristics of home health patients. Under the new regulation, these data will replace the patient assessment protocols that home health agencies are currently required to use for Medicare beneficiaries. HCFA said that more complete patient information will allow physicians, home health agencies, and patients to measure individual patient outcomes and make better treatment decisions.

The OASIS data is also crucial to the development of the prospective payment system (PPS), which the Balanced Budget Act of 1997 (BBA) requires to be in place by Oct. 1, 2000. In her interim report to Congress last month on the progress of PPS, Department of Health and Human Services (HHS; Washington) Secretary Donna Shalala said that because there must be national data to accurately develop the rate structure under PPS, it is critical that these data be collected and reported "as soon as possible."

The new rules confirmed the fears of the home care industry. "They didn’t change any of their positions," the National Association for Home Care’s Mary St. Pierre (NAHC; Washington) told HHBR. "There are no further concessions on cost reimbursement, and the regulations will apply to all patients." The industry had urged HCFA to apply the new requirement only to Medicare and Medicaid patients and to require collection of only core data elements needed for development of PPS. The industry also sought additional payments for the cost of implementing the new requirement.

NAHC said HCFA is underestimating the cost the new rules will impose on home health agencies. "NAHC believes that HCFA has grossly underestimated the actual costs to home health providers of implementing OASIS," said NAHC. "In addition to the already insufficient reimbursement for costs associated with OASIS, HCFA has acknowledged that about 70% of agencies will not receive any adjustment because they have reached their per-beneficiary limits under the interim payment system." NAHC urged all home care providers to submit public comment to HCFA regarding these costs within the required 15 working days.

To determine patient needs, home health agencies will complete the patient assessment within 48 hours after it begins providing care. A patient-specific comprehensive assessment must be performed on each patient receiving services from a home health agency, except maternity and pediatric (under 18) patients and persons receiving only housekeeping and chore services. The comprehensive assessment must incorporate the current version of OASIS, using exact language and groupings. However, the order of the OASIS data grouping within the comprehensive assessment may be determined by each agency. Among the other key provisions included in the final regulation are the following:

Eligibility for the Medicare home health benefit, including homebound status, must be determined both at the time of the initial assessment visit and at the time of the comprehensive assessment.

The initial assessment visit must be conducted by a registered nurse (unless a patient is receiving only rehabilitation therapy services) within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician-ordered start of care date. An occupational therapist may perform the initial assessment visit for non-Medicare patients.

The comprehensive assessment must be completed in accord with the patient’s needs, but no later than five calendar days after the start of care, by a registered nurse (or therapist if a patient is receiving rehabilitation therapy services only).

The comprehensive assessment must include a review of all medications the patient is receiving and identify potential adverse reactions, ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance.

The comprehensive assessment must be updated and revised (including OASIS) as frequently as the patient’s condition changes, but not less often than: (1) every second calendar month, (2) within 48 hours of the patient’s return home from a hospital stay of 24 hours or more (unless diagnostic only), and (3) at discharge.

As with the initial assessment, occupational therapists may do comprehensive assessments for all non-Medicare patients. They may also do the comprehensive assessment on Medicare patients where continued occupational therapy is the qualifying skilled service for Medicare eligibility.

The interim final rule for reporting the data includes these provisions:

Home care agencies and their contracted agents must ensure the confidentiality of a patient’s identifiable information.

Agencies must electronically report all OASIS data collected in accord with the comprehensive assessment regulation to the state agency or HCFA OASIS contractor.

OASIS data must be accurately encoded and ready for transmission within seven days of completing an OASIS data set.

The encoded OASIS data must accurately reflect the patient’s status at the time of the assessment.

Accurate, encoded, and locked OASIS data must be transmitted to the state agency or HCFA OASIS contractor at least monthly for all assessments completed in the previous month and in the format specified by HCFA.

Data must be transmitted using a direct telephone connection from the agency to the state agency or HCFA OASIS contractor.

Data must be encoded and transmitted using software supplied by HCFA or that conforms to HCFA specifications.