Home Health Coding and OASIS Expert

Proposed rule paves the way to linking outcomes and reimbursement.

Your OASIS outcomes could have a direct impact on your agency’s bottom line if CMS’s pay for performance plans for Medicare HHA payments move forward.

The Centers for Medicare & Medicaid Services is considering implementing a P4P program, now known as Value-Based Purchasing (VBP), in January 2016, the agency reveals in the 2015 home health prospective payment system proposed rule issued July 1.

“As currently envisioned, the HHA VBP model would reduce or increase Medicare payments, in a 5-8 percent range, depending on the degree of quality performance in various measures to be selected,” according to the rule published in the July 7 Federal Register.

Watch out: HHAs should be most worried about the big chunk of their reimbursement that will be at stake under the program, warns Pat Laff with Laff Associates in Hilton Head Island, S.C. As CMS points out in the rule, hospital VBP ties only 1.25 percent of hospital payments to VBP this year (that will increase to 2 percent by 2017). In contrast, CMS wants to make up to 8 percent of HHAs’ reimbursement dependent on their outcomes under VBP.

The amount of reimbursement you would put at risk under the 5 to 8 percent VBP pool dwarfs the payment changes in this rule, Laff points out. HHAs that are currently under the state and national outcomes benchmarks are at highest risk for losing that chunk of payment.

CMS doesn’t propose specific outcomes measures for use in the model, but you can bet rehospitalization and emergent care standards will be at the top of the list, Laff tells Eli.

“Everybody better get on their toes,” Laff exhorts. That means examining your outcomes and identifying opportunities to improve them.

To achieve better outcomes, HHAs will need to drill down to data on the clinician and supervisor level, Laff advises. “To fix problems, you have to know who’s pulling you down,” he explains.

Do this: Don’t delay in starting work to improve your outcomes data, Laff counsels — before 5 to 8 percent of your reimbursement depends on it. “This is not something that is just going to happen overnight,” he says. For most providers, it will require systemic change that will take time.

Step Up Your OASIS Submission Rates

Outcomes aren’t the only OASIS area under fire in the proposed rule. Your OASIS submission rates are also targeted for additional scrutiny.

For the first time, CMS will require a “minimum submission threshold” for OASIS. CMS plans “to require all HHAs to achieve a Pay-for-Reporting performance requirement compliance rate of 90 percent or more,” the agency says. In other words, HHAs must submit both admission and discharge OASIS assessments for a minimum of 90 percent of all patients with episodes of care occurring during the reporting period, CMS explains in a fact sheet about the new rule.

“Only those OASIS assessments that contribute, or could contribute, to creating a quality episode of care are included in the computation” for the benchmark, CMS notes in the rule.

However, CMS will give agencies some time to come into compliance with the new requirement.

The agency proposes that agencies must submit 70 percent of “Quality-Assessment-Only” assessments in 2015, 80 percent of QAO assessments in 2016, and then reach 90 percent in 2017.

The consequence: HHAs who do not meet the QAO metric benchmark will face a 2 percent reduction the following year, CMS says.

Note: See the proposed rule at https://www.federalregister.gov/articles/2014/07/07/2014-15736/medicare-and-medicaid-programs-cy-2015-home-health-prospective-payment-system-rate-update-home.