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By Elizabeth E. Hogue, Esq.
(Editor’s note: This is one of a continuing series about legal and ethical issues related to the implementation of the prospective payment system.)
Assessments of patients’ conditions and recording assessment information on OASIS forms play an integral role in the new prospective payment system (PPS) for home health agencies. As just one of many examples, assessment information determines the Home Health Resource Group (HHRG) into which patients are placed. The amount of reimbursement received by agencies is, in turn, closely related to the HHRG into which each patient is placed. That said, accurate assessment of patients, including placing assessment information onto OASIS forms, is one of the most critical steps for the success of agencies under PPS.
A further reason why accurate assessment of patients is so important is that it’s part of an overall campaign to prevent fraud and abuse. When inaccurate assessments result in placement of patients in incorrect HHRGs, agencies may find that they are engaging in fraud and abuse in the form of overutilization or underutilization of services. These types of fraud constitute violations of the False Claims Act, a federal statute.
In view of the importance of the correct completion of OASIS forms, it is not surprising that a number of issues with legal and ethical implications have already arisen. One of these issues involves the role of practitioners in the completion of the OASIS forms.
Because of the question-and-answer format of OASIS forms, it may be tempting for staff to view their role as that of a reporter, i.e., someone who simply asks patients questions and records the information patients provide on the forms in front of them. On the contrary, the Centers for Medicare and Medicaid Services (CMS, formerly HCFA) has made it clear that providers must play a more active role in completion of these forms.
For example, it has been reported that officials at one of the fiscal intermediaries have informed agencies that the intermediary will conclude that patients are not homebound if the OASIS form indicates that they can shop with assistance. Staff at the intermediary may reach this conclusion even if other information on the OASIS indicates that the functional limitations of patients are so severe that the patient in question could not possibly shop with assistance.
So why are providers submitting such inconsistent, and potentially harmful, information on OASIS forms? It appears likely that these results occur because practitioners are simply asking patients if they can shop with assistance, and patients state that they can do so. Without exercising any professional judgment, practitioners are simply reporting the answers that patients provide. To that extent, it is clear that practitioners must play a much more active role in completion of the OASIS form. They must exercise professional judgment so that the inconsistent results described above are avoided.
The stakes are high. Agency managers know that regulators will be looking for instances of fraud and abuse under PPS in the form of underutilization of services. When providers fail to exercise professional observation and assessment to complete the OASIS accurately, despite patient reports to the contrary, the result may be instances of underutilization.
Agencies also should be mindful of the risk-management implications of OASIS forms. These forms require short answers. They do not appear to allow for elaboration of information that may be necessary in order to have an accurate picture of the patient’s clinical condition.
Again, field staff should enter additional information directly onto OASIS forms if such information is necessary to portray patients’ conditions accurately. In other words, OASIS forms are a crucial part of patients’ medical records. Despite the question-and-answer format of the forms, practitioners are nonetheless required to comply with applicable standards of care regarding documentation that includes all necessary information regarding assessment of patients’ conditions. Such information may also assist agencies in defending themselves should there ever be allegations of fraud and abuse.
The additional information that practitioners may enter onto OASIS forms will not, of course, be transmitted to CMS. But it will be available for review by regulators, patients and their families, and attorneys for patients, if the quality of care rendered by agencies is questioned.
The standardization of home care documentation through the use of OASIS forms may produce beneficial results for both agencies and patients. Practitioners should bear in mind, however, that CMS’ mandate to use certain forms for assessments of patients does not change applicable standards of care regarding assessments of patients’ conditions and documentation of the results of these assessments.