A recent report released by the Office of Inspector General (OIG) on September 5th revealed that home health agencies (HHAs) failed to properly document and report a significant number of fall incidents with major injuries, among Medicare patients.

According to the report, 55% of major injuries resulting from falls were inaccurately documented in the OASIS. Furthermore, there were several instances where the OASIS was not transmitted at all. This underscores significant concerns about potential data submission noncompliance, thereby compromising the accuracy of information on falls leading to major injuries, which offer valuable insights into care effectiveness.

Notably, home health agencies (HHAs) with the lowest Care Compare major injury fall rates report fewer falls than HHAs with higher Care Compare fall rates. This suggests that Care Compare does not provide accurate information about the frequency of falls among home health patients, thus impacting the perception of care quality provided by these agencies.

To delve deeper into the issue, it is crucial to note that falls often occur when patients are supervised by caregivers when no HHA personnel is present. Hospitals may also fail to share accurate patient information due to a misunderstanding of HIPPAA or the lack of shareable data. As a reult, HHAs may complete the assessments for hospitalized patients with fall-related major injuries based on inaccurate information.

The OIG recommended corrective action which CMS agreed to. One notable recommendation by OIG is for CMS to assess the potential benefits of implementing automated checks to identify inpatient hospital claims and encounters for home health patients. If these checks reveal that the required OASIS assessments haven’t been submitted promptly, CMS should notify home health agencies (HHAs). This proactive approach could potentially enhance the reporting rates for falls with major injuries.

Documenting Falls Resulting in Injuries and Hospitalization

With the OIG findings and recommendations for CMS, we can expect stricter scrutiny for HHAs for timely completion of OASIS and accurate completion of the OASIS assessments on injuries resulting from falls.

If a patient is hospitalized for more than 24 hours (excluding standard tests), the HHA must complete an OASIS Transfer, which includes items J1800 and J1900 used to document incidents of falls and assess their severity.

J1800 allows you to record that the patient experienced a fall. J1900 is used to document the severity of that fall. It details whether there was an injury related to the fall, if there was no injury, if there was an injury but not a major one, or if there was a major injury.

The ‘Major Injury’ option on the OASIS includes bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. These should be reported if they are the result of a fall. Additionally, any injury that resulted from a fall, not on the list of major injuries, should be recorded as Injury (Except Major) on the OASIS.

HHAs must provide adequate OASIS training for staff, particularly focusing on fall-related incidents. Additionally, the Quality Assurance (QA) team should play a role in reviewing data accuracy to ensure the Transfer OASIS is complete and accurate, and that it’s submitted promptly to the OASIS database.

The post OIG Report Inadequate OASIS Documentation of Falls with Major Injury first appeared on Qavalo.

When OASIS submission, coding, and QA review were streamlined, Qavalo’s client agencies saw significant improvements in their OASIS turnaround time and realized better compliance and profitability.

With the right outsourcing partner, Qavalo clients have been able to get the support their in-house teams need to find efficiencies in their documentation workflow and seize big picture process improvement opportunities.

Benefits Realized

• Consistent OASIS submission-to-completion process
• Faster OASIS submission time
• Shorter OASIS turnaround time
• Declining LUPA rates
• Optimized reimbursement values

PDGM Turnaround Time Challenges

The Patient-Driven Groupings Model (PDGM) overhauled the entire home health reimbursement system with new case-mix weight calculations, new LUPA thresholds, new Request for Anticipated Payment (RAP) requirements, and shorter payment periods, among other big changes.

Request for Anticipated Payment (RAP)
In 2020, CMS introduced RAP, requiring agencies to submit initial documentation to authorize care under a home health agency and establish the care episode. Though a complete OASIS is no longer a requirement to file a No-Pay RAP this year, it is still best for agencies to complete the OASIS within the 5-day window period.

HHRG and HIPPS codes
Based on an OASIS assessment, 30-day periods under PDGM are classified under a variety of patient information and other clinical characteristics, such as admission source, timing, clinical grouping, functional impairment, and comorbidity. This results in a Home Health Resource Group (HHRG) combination for which CMS will generate a PDGM case-mix weight represented as a Health Insurance Prospective Payment System (HIPPS) code on Medicare claims.

Completion of the OASIS in time for RAP filing allows agencies to determine the claim’s HHRG classification and a HIPPS code that is more reflective of the actual patient case. This is important so that the assigned HIPPS code in the RAP would be more consistent with the HIPPS code in the final claim, thus lowering the chance of the agency being flagged for an Additional Development Request (ADR).

Low Utilization Payment Adjustments (LUPA)
With PDGM, LUPA thresholds vary per HHRG over a 30-day period, which means agencies should closely monitor different LUPA thresholds and visit intensities for each patient. Early identification of the LUPA threshold though the HHRG and HIPPS code will help agencies plot and schedule visits accordingly to prevent claims falling under LUPA.

These changes underscore the need for home health agencies to fast-track their process, improve documentation turnaround, and observe strict OASIS completion timelines in order to address key functions that affect claims approvals and reimbursement values. This is no easy task since an OASIS needs to undergo a number of processes, including coding and QA review, before being completed. In many cases, this can take up to 10 days—or ⅓ of the care period—if processes are not streamlined.

Qavalo Solutions in Numbers

To address the abovementioned challenges, Qavalo applies several workarounds and best practices to help agencies achieve the ideal workflow and succeed in timely submissions. 

• Timely coding and OASIS review to allow agencies to identify LUPA thresholds ahead of time, and generate a HIPPS code that is reflective of the actual patient case.
• Coding is done as soon as the OASIS is available in the QA manager.
• Coders are available seven (7) days a week.
• OASIS QA review is completed within 48 hours after coding.
• There is efficient resolution of escalations of OASIS quality issues.
• Qavalo proactively notifies agencies of trends on late submissions of OASIS by the clinicians.

Figure 1.1 shows the average OASIS submission time of clinicians across all home health agency clients of Qavalo. In January 2021, average OASIS submission was at 2.52 days, and by May 2021, this decreased to only 1.41 days.

More importantly, figure 1.2 below shows the average OASIS turnaround time from clinician submission to final approval. From January to May of 2021, Qavalo home health agency clients were able to realize completion of the OASIS within an average of 3.16 days.

Though a complete OASIS is not required to submit No-Pay RAPs since January 2021, clinicians were able to maintain early submission of OASIS, allowing other OASIS processes,  such as coding and QA review, to be accomplished in a timely manner. In addition, Qavalo’s QA review program supports clinician reeducation, helping them improve their charting skills overtime. This resulted in an efficient end-to-end average OASIS turnaround time of 3.16 days, which falls within the 5-day RAP filing window.

Due to efficiencies in the OASIS completion timeline, LUPA thresholds were identified early on in the payment period, allowing agencies to properly plot visit schedules, and anticipate and address missed or cancelled visits, thus avoiding LUPAs.

Figure 2 below shows sample data from one of Qavalo’s clients, Palmeria Home Health in Arizona and Nevada. The graph shows the percentage of Palmeira’s LUPA episodes from the fourth quarter of 2020 to the second quarter of 2021.

In Q4 of 2020, only 7% of all episodes fell under LUPA. Even with the implementation of No-Pay RAPs in 2021, when the OASIS is no longer required to be completed within 5 days, LUPA rates continued to drop at 6% by Q1 and down to only 4% by Q2.

While early identification of LUPA thresholds greatly helped agencies, LUPAs were not completely avoided because of some uncontrollable factors such as cancelled visits due to patients’ anxiety towards COVID-19.

The Right Partner for the Job 

Based on data, Qavalo’s home health agency clients realized a better OASIS turnaround time. Beyond the scope of documentation review and coding, Qavalo maintains ongoing collaboration with in-house teams and leverages data to help agencies have a comprehensive view of their documentation workflow and properly address gaps. This path of progress will only lead to more streamlined processes, resulting in better patient outcomes and business profitability.

The post PDGM Challenges: Optimizing Profitability Through Efficient OASIS Turnaround first appeared on Qavalo.