OASIS data key to maximizing PPS reimbursement, says expert


HHBR Washington Correspondent

WASHINGTON – Accurately completing the Outcome and Assessment and Information Set (OASIS) will have a major impact on the per-episode payment that home health agencies receive under the prospective payment system (PPS). Cynthia Hohmann, vice president and chief operating officer for HCMC (Jacksonville, FL) said that is why agencies must master the OASIS question set before PPS is implemented next fall.

Hohmann, who advised agencies on how to improve their use of OASIS at the National Association for Home Care’s (Washington) recent National Policy Conference in Washington, noted that she attended all of the Health Care Financing Administration’s (HCFA; Baltimore) training sessions for surveyors and OASIS coordinators and points out that they are also in a learning mode.

Hohmann told agencies that she has performed more than 40 OASIS accuracy audits since last September and has found discrepancies and inaccurate answers made by nurses or therapists in each one. "The discrepancies in answers are not intentional," she said. "It is a lack of training." In fact, many agencies had not reviewed the OASIS training manual in months, she added.

According to Hohmann, many inaccuracies also had to do with interpretation. "Many of the nurses and therapists were interpreting the questions and answers on their own," she told agencies. But she emphasized that the OASIS manual must be followed verbatim, item by item .

Hohmann added that many of the mistakes made on the OASIS assessment were attributable to the fact that nurses were not getting enough information from the intake process or referral form. She advised agencies to modify those forms for OASIS by including some of the OASIS questions that must be answered during intake.

Hohmann said this is especially important for questions relating to the dates and places patients have had in-patient treatment, as well as their diagnoses.

"This is important not only for PPS but also the areas where they are looking for fraud," she said. If HCFA believes agencies are putting one diagnosis on the OASIS assessment to generate a certain home health resource utilization group (HHRG), but a different diagnosis on the 485, they will likely run into trouble, she warned.

HCFA zeroes in on fraud

In addition to tracking their costs for specific diagnoses, home health agencies must track how many patients are readmitted after discharge after a 60-day episode to either a hospital or a home health agency through a doctor’s office, according to Hohmann.

"That is something you are going to need to be looking at because your readmissions within the same 60 days is going to have an impact not only on your PPS rate, but in the area of quality of care," she said.

Hohmann pointed out that HCFA, through its intermediaries and surveyors, is going to be looking at whether agencies provided enough services or visits in those 60 days. "Intermediaries will be looking at end results," she noted. "Whatever you elect to choose per patient, per HHRG, what they are going to come back and look at is your end results – meaning how your patients have improved or not improved."

They are going to be using outcome reports from the OASIS assessments as a guide to help determine which agencies they need to examine, she added.

"The code that is going to generate your payment is not going to come from the 485," she emphasized. "It is going to come from the OASIS information that is submitted into your billing system through whatever type of software system you have."

Hohmann said that one thing she did was train nurses to understand that "profit" was not going to be a dirty word under PPS. "Your nurses must understand that profit is not a bad thing," she said. "Instead, they should be reminded that profit can be used to help care for other patients."

As part of her assessment, Hohmann said that she takes the clinical component and determines clinical severity. She then looks for incorrect answers and determines what the appropriate payment should have been.

Hohmann said she started using a PPS scoring sheet with the answers included on the OASIS assessment. "That is when I found out that the because of inaccuracies, many patients were being scored way below what they should have been scored within the 80 groups," she said.

She added that while agencies may opt to begin with the 19 items that are part of the scoring, there are several other OASIS questions that will have significant impact as well. "It is really the overall OASIS assessment that you must be looking at for accuracy," she said.

"One of the things they have enabled you to do when you find incorrect answers is to go back and correct them," she noted.

In addition, Hohmann said that surveyors have been advised that once they are familiar with the assessment, they can use certain portions of it to deny homebound or medical necessity. "They are not only looking at it for survey purposes," she said. "It is probably also going to be part of focused medical review."

In short, Hohmann reminded agencies that through OASIS, nurses and therapists will be determining how much agencies are paid per 60-day episode. That determination will be made by the answers given, as well as the frequencies and the different services and disciplines they put into place.

"For that reason, you are going to have to do the initial OASIS from the start of care to initiate the payment process and every 60 days after that for recertification or readmission," she said. Agencies will also have to note significant changes in condition. "I recommend you start practicing that now because it is in the regulation," she added.

"The reason a lot of people have not been doing it is that there has not been a definition of significant change in condition’," said Hohmann. But she noted there are some guidelines that require this even if the patient is not readmitted to the hospital, but an increase in visits for more than a week is required, especially in the area of skilled nursing.