Home Health & Hospice Week

Watch out: Extremely low falls QM figures may become a red flag.

Providers self-reporting quality data has long been a cause for concern, and a new report from a federal watchdog agency shows why.

“Among Medicare home health patients hospitalized for falls with major injury, over half of the falls were not reported on patient assessments by HHAs as required,” the HHS Office of Inspector General says in the report. “Fifty-five percent of falls we identified in Medicare claims were not reported in associated OASIS assessments,” the OIG specifies.

And that figure is almost surely even higher in reality. “We were unable to identify any transfer or discharge OASIS assessment completed around the time of the hospitalization for 5,757 falls (13 percent of the total falls we identified) that resulted in a major injury among home health patients,” the OIG reports. The audit period ran from July 2020 to June 2021.

“While we excluded falls that could not be linked to OASIS transfer or discharge assessments from our non-reporting analysis, treating these falls as not reported would increase the overall non-reporting rate from 55 percent to 61 percent,” the OIG calculates.

And investigators probably didn’t even find all of the falls and related hospitalizations that would necessitate a report via OASIS, the OIG adds. “We may not have identified falls with major injury among home health patients if the inpatient hospital claims did not fully capture the cause and extent of patients’ injuries,” the report points out. And “Medicare Advantage encounter records are often less complete than Traditional Medicare claims. As a result, we may not have identified all falls leading to hospitalization among people enrolled in Medicare Advantage.”

In fact, the audit found that falls for MA patients could be significantly further underreported than those for fee-for-service beneficiaries. “Most falls occurred among FFS enrollees, and we were able to link to OASIS assessments for all but 8 percent of these falls,” the OIG notes. “In contrast, for Medicare Advantage enrollees, we could not find OASIS assessments for 29 percent of falls.”

The OIG’s findings don’t exactly come as a shock to industry veterans.

“I am not the least bit surprised with [these] OIG findings,” says consultant Pam Warmack with Clinic Connections in Ruston, La. “Reporting of falls has been a deficiency for quite a long time,” Warmack tells AAPC.

“For over two decades I have been preaching that we have to be honest and accurate when collecting all of the OASIS items,” stresses consultant Cindy Krafft with Kornetti & Krafft Health Care Solutions in Florida. “Had we done that as an industry as a whole, the data would be correct and usable for appropriate quality measures and payment models,” Krafft maintains.

Low Falls Rate Points To OASIS Noncompliance, OIG Says

Further analysis by the OIG uncovered these findings:

• The falls in the report occurred for 38,580 people served by more than 6,180 home health agencies.
• For-profit HHAs did not report 56 percent of their patients’ falls, while nonprofit and government-owned HHAs did not report 52 percent and 38 percent of falls, respectively.
• Falls non-reporting rates were higher for Hispanic (64 percent), Black (65 percent), and Asian (66 percent) people compared to White (54 percent) people.
•  Falls non-reporting rates were higher for patients less than 65 years of age (64 percent) versus patients 85 years of age and older (52 percent).

Furthermore, investigators found that HHAs reporting the lowest fall rates actually had the most missed falls. “HHAs with the lowest Care Compare major injury fall rates reported falls less often than HHAs with higher Care Compare fall rates, indicating that Care Compare does not provide the public with accurate information about how often home health patients fell,” the OIG charges.

Specifically, “the HHAs in our study with low fall rates on Care Compare failed to report 78 percent of the falls we identified in the Medicare claims. In contrast, the HHAs in our study with high fall rates on Care Compare failed to report 43 percent of the falls we identified in the Medicare claims,” the OIG reveals. (The agency defined low fall rates as less than 0.4 percent, medium fall rates as 0.4 percent to 1.2 percent, and high fall rates as 1.2 percent and higher.)

For example: The report cites an example of a large, for-profit HHA in Florida with a five-star quality rating on Care Compare. This agency reported zero of 18 falls its patients experienced in the audit period, the OIG highlights. The agency’s 0.4 percent figure for the falls QM on Care Compare “is much lower than the average percent (1 percent) reported by other HHAs in this study,” the OIG points out.

In a nutshell, “a low fall rate on Care Compare may reflect an HHA’s lack of falls reporting, rather than a low incidence of falls among its patients,” the OIG theorizes.

“I do think OIG is accurate in their findings,” Warmack observes.

“Recent audits we have been doing at K&K keep showing OASIS responses being influenced by payment and/or quality implications,” Krafft acknowledges.

“It always amazes me that the percentage of major falls for several of my clients is significantly higher than others,” Warmack tells AAPC. But “that is because other agencies are not reporting,” she concludes. In contrast, her clients have “made it a priority to report all falls correctly and consistently,” she relates.

The concept of unreliable OASIS data is hardly new. Most recently, in its latest report on the Home Health Value-Based Purchasing pilot project, CMS noted that OASIS coding creep was the only explanation for improvements in patients’ functional status over the course of the program (see HHHW by AAPC, Vol. XXXII, No. 19).

Bottom line: Cumulatively, these problems and results point to a big difficulty, the OIG warns. “The home health falls with major injury quality measure published on Care Compare provides the public with inaccurate information about how often people using home health services fell,” according to the agency. v

Note: The 34-page OIG report is at https://oig.hhs. gov/oei/reports/OEI-05-22-00290.pdf.