Home Health Quality Reporting Requirements
Statutory Authority for Use of the OASIS Data Item Set and Home Health Quality Reporting
The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895(b)(3)(B)(v)(II) of the Social Security Act (“the Act”). This statute 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.’’
Outcome and Assessment Information Set (OASIS) reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250(a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895(b)(3)(B)(v) of the Act.
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.’’
The requirement that HHAs report quality data to CMS is contained in the Medicare regulations. Section 484.225(i) of Part 42 of the Code of Federal Regulations (C.F.R.) provides that HHAs that meet the quality data reporting requirements are eligible to receive the full home health (HH) market basket percentage increase. HHAs that do not meet the reporting requirements are subject to a two (2%) percentage point reduction to the HH market basket increase. Section 1895(b)(3)(B)(v)(III) of the Act states that ‘‘[t]he Secretary shall establish procedures for making data submitted under subclause (II) available to the public. Such procedures shall ensure that a home health agency has the opportunity to review the data that is to be made public with respect to the agency prior to such data being made public.’’
The Home Health conditions of participation (CoPs) which are contained in 42 C.F.R., section 484.55(d) require that HHAs must update and revise the comprehensive assessment (including the administration of the OASIS) no less frequently than: (1) The last 5 days of every 60 days beginning with the start of care date, unless there is a beneficiary elected transfer, significant change in condition, or discharge and return to the same HHA during the 60-day episode; (2) within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and (3) at discharge.
It is important to note that to calculate quality measures from OASIS data, there must be a complete quality episode, which requires both a Start of Care (initial assessment) or Resumption of Care OASIS assessment and a Transfer or Discharge OASIS assessment. Failure to submit sufficient OASIS assessments to allow calculation of quality measures, including transfer and discharge assessments, is failure to comply with the CoPs. HHAs do not need to submit OASIS data for those patients who are excluded from the OASIS submission requirements. As described in the December 23, 2005 Medicare and Medicaid Programs: Reporting Outcome and Assessment Information Set Data as Part of the Conditions of Participation for Home Health Agencies final rule (70 FR 76202), we define the exclusion as those patients:
- Who are receiving only non-skilled services;
- For whom neither Medicare nor Medicaid is paying for HH care (patients receiving care under a Medicare or Medicaid Managed Care Plan are not excluded from the OASIS reporting requirement);
- Who are receiving pre- or post-partum services; or
- Who are under the age of 18 years.
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, 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 HHAs meet Federal reporting requirements for the OASIS data; (2) Determine the extent to which states meet federal reporting requirements for OASIS data; and (3) Determine the extent to which the CMS oversees the accuracy and completeness of OASIS data submitted by HHAs. In a 2012 report entitled, “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 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 that create a quality episode of care during the reporting period or are consistent with creating 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 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 65 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 beginning in the previous reporting period, (that is, an EOC that occurs in the first 65 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 65 days of the performance period. This is labeled as an “SOC/ROC Pseudo Episode” quality assessment.
- An EOC assessment that is preceded by one or more Follow-up assessments, the last of which occurs in the first 65 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.
- 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.
- SOC, ROC, and EOC assessments that do not meet any of these definitions are labeled as “Non-Quality” assessments.
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
We require all HHAs to achieve a quality reporting compliance rate of 90 percent or more, as calculated using the QAO metric illustrated above.
For more information about the methodology of the “Pay-for-Reporting Performance Requirement” please review the document titled “Pay for Reporting: Quality Assessments Only Methodology” which is available in the Downloads section below. For more information about reconsideration, exemption, and extension, including in the case of natural disasters, please navigate to the Home Health Quality Reporting Reconsideration and Exemption & Extension webpage.
- CY17 Home Health Final Rule
- CY18 Home Health Final Rule (PDF)
- CY19 Home Health Final Rule
- CY20 Home Health Final Rule