OASIS Alert

Hold regular OASIS training to see a positive impact on case mix -- and reimbursement.

Improving your case mix accuracy could add thousands of dollars in reimbursement to a single home health episode. But if your clinicians aren't accurately determining case mix classifications, your agency will lose out.

"With 153 possible combinations that generate case mix weights, it's easy to stray from total OASIS accuracy," says Pat Jump, MA, BSN, RN, COS-C, with Rice Lake, Wis.-based Acorn's End Training & Consulting. But this wandering can cost your agency dearly.

Mistake: "In essence, when OASIS assessments are inaccurate or the clinician fails to accurately answer the OASIS data items, the provider 'donates' money back to CMS," Jump warns.

Watch for Survey Citations

Research shows that case mix inaccuracy tends to err in favor of Medicare and against the provider, Jump says. For example, clinicians tend to rate the client as more independent than they actually are in items like M1850 -- Transferring and M1830 -- Bathing.

"When I conduct clinical chart audits, invariably I find that the OASIS assessment does not reflect the severity of the client's health situation as noted in the clinical notes," Jump laments. The financial risk in this situation is multi-factored, she says.

"First and foremost, the provider is 'leaving money on the table' by not obtaining an accurate case mix because of inaccurate OASIS assessments," Jump says. "Additionally, the provider is at risk of survey citations because of inconsistency in client health status information and down-coding because of poor or inaccurate information."

There are some common case mix errors you can spot before they have a negative impact on your bottom line. Correct these mistakes to keep your case mix well within standard benchmarks.

Mistake #1: Asking instead of looking. Which assessment technique do you think will yield more accurate information: Asking a patient "How far can you walk?" or watching the patient walk? "These are two totally different things," says Beth Carpenter, a Lake Barrington, Ill.-based consultant with Beth Carpenter & Associates. One reason completing the OASIS takes so long is because it is supposed to be assessing functionality.

One of the biggest mistakes providers make is to assume a clinician really knows how to comprehensively complete a head-to-toe assessment, Jump says. Most nurses learn how to do this assessment in a nursing lab setting or perhaps in an institutional setting, she says. Seldom do providers teach nurses how to do a comprehensive head-to-toe assessment in the home environment.

Real world: There is a difference between the lab and the home setting, Jump points out. "Not once, when I learned to do a head-to-toe assessment in the nursing school's clinical lab, did I have a dog barking or a baby crying in the background. I did not have a fully clothed patient refusing to remove an item of clothing. Nor did I have a family member shouting from the kitchen that dinner was getting cold and the patient should come to the kitchen ... now!"

Solution: Train clinicians to complete an assessment in the home environment and learn action steps to take when barriers prevent best-practice assessments, Jump advises. "At least annually, all clinicians should complete training on conducting a head-to-toe assessment in the home environment."

Mistake #2: Clinicians repeatedly score too high or too low. For a true picture of your agency's case mix accuracy, you should evaluate each clinician's case mix trend. That way, you'll spot whether one practitioner consistently scores her patients' case mix on the high side while another's case mix is consistently low.

Solution: Conduct periodic evaluations of your clinicians' case mix scores. Evaluating the clinicians' case mix over time allows a provider to consider several key areas, Jump says. These include:

• Look for reasons. A clinician could have very high case mix for a variety of reasons, Jump says. She could be artificially inflating the dependency of the client. Or she may be more accurately reflecting the status of the client because she answers the OASIS items accurately. Or he might carry a case load of higher acuity clients. Taking the time to evaluate and compare your clinician's case mix can help get to the reason behind the scores.››
• Consider differences between clinicians. When comparing clinician case mix, keep in mind the OASIS training each clinician has completed, OASIS assessment experience, and other details that may account for the varying case mix weights, Jump advises. Talk to clinicians to gather their ideas regarding the difference in case mix weights between clinicians and provide training where needed. Sometimes, a wide variance in case mix between clinicians indicates a need for remedial OASIS and/or coding training.
• Compare timeframes. Comparison between admission case mix (RAP) trends and claim case mix (end of episode) trends allows you to look at the accuracy of OASIS answers at both time points. If there is a significant difference between admission case mix and claim case mix, find out why.
• Look low. Examine every low case mix weight at admission to determine whether this client really qualifies for Medicare, Jump says. For example, if all of the ADLs are low scores, consider whether or not the client is truly homebound. Recent cases demonstrate that providing care for non-homebound patients can result in fraud accusations and medical review.
• Think national. Compare your agency's average case mix to the national benchmarks to see where you stand overall.

Mistake #3: Addressing case mix only once. Don't just spot-check case mix and then go on about your business. Case mix weights should be monitored and compared frequently.

Solution: At a minimum, review case mix weights at admission and discharge, Jump says. In order to compare RAP and claim case mix, you should also review them at the end of each episode, for clients experiencing more than one episode of care.››

Additionally, you should analyze agency-wide case mix weights at least quarterly to determine trend variances, Jump says. Examine any variance from the previous quarter to determine the reason for the difference.

For example: Is the variance related to a new program that was initiated such as concentrated client referrals from a local orthopedic physician? Or could the difference be related to a spike in clinician turnover in which the agency is working with a large number of new clinicians. Or is the new trend due to a true change in the patient population?

Providers need to know the actual trend and the cause of the variance in trends before they can address any issues that may arise, Jump says.