OASIS Alert

Quality Improvement Organizations insist they're not spies for your local surveyor.

Home health agencies that have survived Operation Restore Trust, overzealous surveyors and the interim payment system aren't the trusting souls they used to be; they raise an eyebrow at anyone who says, "We're from the government and we're here to help you."

The Centers for Medicare & Medicaid Services issued a "roles paper" delineating QIO versus surveyor roles in the Home Health Compare project, where HHAs' patient outcomes are publicly compared in newspapers and on a new CMS Web site. QIOs are charged with helping agencies improve their patient outcomes through outcome-based quality improvement.

When CMS issued the roles paper, legal experts warned that QIOs have wide latitude to report agency activities to surveyors "in situations where there is a need to protect against a substantial risk to the public health" (see Eli's OASIS Alert, Vol. 4, No. 3, p. 24).

And HHAs were little reassured by comments from CMS and QIO representatives at the National Association for Home Care & Hospice's annual policy conference. In an April 7 CMS presentation on surveys, an attendee raised a concern about QIO-surveyor interactions in the question-and-answer session following the talk.

CMS official Heidi Gelzer deferred some of the response to a QIO rep in the audience. "We are responsible to the Medicare beneficiary," the rep stressed.

"Appropriate referrals" are made back and forth between QIOs and surveyors, Gelzer added.

Agencies found more reassuring the QIO rep's promises that the organizations make referrals only for "egregious" situations. "We're not looking for it, but if it's observed we will report it," the rep explained.

Likewise, QIOs will report only "gross and flagrant" violations to surveyors, insists American Health Quality Association spokesperson Dave Adler. The AHQA represents QIOs.

Also reassuring were comments from CMS official Barbara Paul the next day in a panel on home care quality. Information given to a QIO is a "privileged, protected, confidential communication between you and the QIO," she stressed to NAHC conference attendees.

The problem with those assurances, say legal experts, is that they aren't written down anywhere. Instead, the roles paper vaguely sets out that the supposed risk to public health "might involve occurrences which any individual citizen would find unacceptable" or "might be understood as unacceptable by someone with clinical experience.

" But Paul dismissed that provision as a "legal gobbledy-gook out clause for that rare situation that we hope none of us will ever see.

" Adler also notes it's very unlikely that QIOs would be in a position to witness any violations at all. Much of the OBQI help is classroom training and follow-up phone calls.

The QIOs haven't reported any home health transgressions to surveyors yet, "and it is unlikely it would happen," Adler stresses.

"The fear is there" among HHAs, but that doesn't mean they should shun QIOs' help, advises consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD. While QIOs are required to report fraud and abuse, chances are slim that it will affect HHAs. Sevast points to hospitals, which have been working with QIOs, as a successful example of partnering with the organizations.

Missouri Alliance for Home Care Executive Director Mary Schantz is advising members to take advantage of the "great resources and assistance" offered by the state's QIO while maintaining a lookout for any possible "regulatory bent" from the organization. "We have a positive outlook," Schantz tells Eli.

Indiana HHAs count their state's QIO an ally and have worked with the organization in Medicaid, notes Jean MacDonald with the Indiana Association for Home and Hospice Care. "They're just so excited to have a friend" to help with the confusing OBQI process, she says.

Instead of surveyor-QIO conflicts, Indiana agencies are concerned about surveyor-OASIS Education Coordinator conflicts, MacDonald says. In that state, the OEC is also a part of the survey agency, which is likely to make HHAs reluctant to call her, MacDonald worries. Agencies might fear if they call the OEC and admit to being confused on a certain M0 question, for example, she might pass it on to surveyors.