Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
 
L  O
IMITED  VERSIGHT OF 
 
H  H A
OME  EALTH  GENCY 
 
OASIS D  
  ATA
 
Daniel R. Levinson  
Inspector General 
 
February 2012 
OEI-01-10-00460   
 
EXECUTIVE SUMMARY:  LIMITED OVERSIGHT OF HOME HEALH 
AGENCY OASIS DATA:  OEI-01-10-00460 
 
WHY WE DID THIS STUDY  
 
Outcome and Assessment Information Set (OASIS) data are the basis for home health 
agency (HHA) payment, quality measures, and consumer information on the Home 
Health Compare Web site.  Timely and accurate submission of these data is vital for 
HHAs efforts to improve quality and for consumers researching HHAs.  In addition, 
State survey staff use OASIS data in the survey and certification of HHAs, which ensures 
that HHAs are meeting all Conditions of Participation required by Medicare.   
 
HOW WE DID THIS STUDY 
 
We surveyed all States regarding their responsibilities for OASIS data.  We conducted 
structured interviews with Centers for Medicare & Medicaid Services (CMS) staff.  We also 
obtained all home health Part A claims and OASIS records for 2009 to determine which 
submitted claims were missing a required OASIS record.  We obtained a list of all HHAs 
that CMS penalized from 2007 to 2010 by assessing the 2-percent payment reduction.  
 
WHAT WE FOUND 
 
HHAs did not meet all Federal reporting requirements.  They did not submit required 
OASIS data for 392,180 (6 percent) of claims in 2009, which represented over $1 billion 
in Medicare payments.  Only 199 HHAs were penalized by CMS with the 2-percent 
payment reduction from 2007 through 2010.  Furthermore, HHAs submitted 15 percent 
of OASIS datasets late.  Some States provided training and technical support to HHAs 
and almost all restricted access to OASIS data.  States conducted limited data analysis 
and review of the accuracy of OASIS data.  Finally, CMS did not ensure the accuracy or 
completeness of OASIS data and did not validate States processes for monitoring 
submitted OASIS data. 
 
WHAT WE RECOMMEND 
 
Our report made three recommendations to CMS.  First, identify all HHAs that failed to 
submit OASIS data and apply the 2-percent payment reduction to them.  Second, establish 
and implement enforcement actions for HHAs that submit OASIS data after the 30-day 
deadline.  Third, develop clear guidelines that delineate expectations for States regarding 
timely and accurate OASIS data.  CMS concurred with our first recommendation and did 
not concur with our second or third recommendation. 
   
 
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................4 
Findings........................................................................................................6 
Home health agencies did not meet all Federal reporting 
requirements for OASIS data ...........................................................6 
States met some, but not all, OASIS requirements ..........................8 
CMS did not ensure the accuracy or completeness of OASIS     
data ...................................................................................................9 
Recommendations ......................................................................................10 
Agency Comments and Office of Inspector General Response ..... 11 
Appendix A ................................................................................................13 
Agency Comments .........................................................................13 
Acknowledgments......................................................................................18 
 
   
   
OBJECTIVES 
1.  To determine the extent to which home health agencies (HHA) meet 
Federal reporting requirements for the Outcome and Assessment 
Information Set (OASIS) data. 
2.  To determine the extent to which States meet Federal reporting 
requirements for OASIS data.  
3.  To determine the extent to which the Centers for Medicare & Medicaid 
Services (CMS) oversees the accuracy and completeness of OASIS 
data submitted by HHAs.  
BACKGROUND 
Medicare beneficiaries who are generally confined to their homes may be 
eligible to receive certain medical services at home.1  Home health 
services include part-time or intermittent skilled nursing care, as well as 
other skilled care services, such as physical, occupational, and speech 
therapy; medical social work; and home health aide services.2    
OASIS 
When a beneficiary begins home health care, and at regular intervals 
thereafter, a registered nurse or rehabilitation therapist conducts a 
comprehensive assessment of the beneficiary using the OASIS, a 
standardized dataset.3  HHAs use the OASIS to assess patients continuing 
need for home care and to identify patients medical, nursing, 
rehabilitative, social, and discharge-planning needs. 
     
Medicare reimbursement and consumer information presented on CMSs 
Web site depend on accurate and timely submission of OASIS data.  In 
addition, State survey staff use OASIS data in surveying and certifying 
HHAs to ensure that HHAs are meeting all Conditions of Participation 
(CoP) required by Medicare.  Finally, OASIS data will play a crucial role 
as CMS explores pay-for-performance systems that offer incentive 
payments to Medicare HHAs for maintaining high levels of quality care or 
for making significant improvements in the quality of their services. 
Home Health Prospective Payment System   
Under the prospective payment system (PPS), which CMS implemented in 
October 2000, HHAs receive a standardized payment for each 60-day 
episode of home health care that a Medicare beneficiary receives.  The 
 
1 Social Security Act,  1835(a)(2)(A) and 1861(m). 
2 CMS, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 7,  40. 
3 42 CFR  484.55(b) and (d)(1).  
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  1 
   
payment covers skilled nursing care, home health aide visits, therapy, 
medical social services, and routine and nonroutine medical supplies 
provided by HHAs.4  HHAs use the OASIS to determine the payment 
code for each 60-day episode of care they submit for reimbursement.  
Home Health Quality Measures 
CMS uses OASIS data as the basis for its Outcome-Based Quality 
Improvement effort.  CMS developed 41 quality measures to evaluate 
patients improvement or stabilization in activities of daily living and 
health status.  Quality measures include improvement or stabilization in 
bathing, toileting, speech, and language; in cognitive functioning; in 
management of oral medications; and in bowel and urinary continence.  
CMS reports 12 of these quality measures on its Home Health Compare 
Web site, which informs patients and their families about HHAs. 
Overseeing Medicare HHAs 
Through agreements between CMS and the States, State survey agencies 
(State agencies) survey HHAs to certify their compliance with Medicare 
CoPs.5  State agencies conduct initial onsite certification surveys before 
HHAs enroll as Medicare providers, and the States conduct recertification 
surveys at least every 36 months.6  State agencies have the authority to 
cite HHAs for failure to meet the standards specified in the CoPs.  State 
agencies review OASIS data to prepare for surveys of individual HHAs 
and to audit the accuracy of OASIS data.7  The CMS OASIS Guidance 
Manual instructs HHAs on how to verify OASIS accuracy through clinical 
record and data entry audits.  As part of the survey, CMS expects State 
agencies to examine how HHAs monitor the accuracy of OASIS data; to 
review clinical records; and to observe a home visit, if possible.8 
Transmitting OASIS Data 
CMS requires HHAs to submit OASIS data to their States for all Medicare 
beneficiaries they serve.9  State agencies are responsible for collecting and 
managing OASIS data.  The CMS OASIS submission system, housed in 
State agencies, automatically validates transmitted OASIS data.  The 
system rejects submissions with significant data problems, but it does not 
prevent transmission of records with minor errors.  HHAs receive 
confirmations when data transmissions are complete.  A CMS contractor 
 
4 65 Fed. Reg. 41128 (July 3, 2000). 
5 Social Security Act,  1864. 
6 Social Security Act,  1891(c)(2)(A). 
7 42 CFR  488.68(c). 
8 CMS, State Operations Manual, Pub. No. 100-07, Appendix B, Section G322,  484.20(b). Standard:  
Accuracy of Encoded OASIS Data. 
9 HHAs must submit an OASIS for all Medicare and Medicaid patients; however, this study is limited to 
Medicare patients.  
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  2 
   
collects the data from all State agencies and computes the quality 
measures that CMS uses for monthly Outcome-Based Quality 
Improvement Reports and quarterly updates to its Home Health Compare 
Web site. 
CMS requirements for HHA OASIS submission.  CMS requires that all 
HHAs encode and electronically submit OASIS data to State agencies 
within 30 calendar days after completing each patient assessment.10, 11  It 
also requires HHAs to ensure that submitted data accurately reflect the 
condition of each patient at the time of assessment.12 
The Deficit Reduction Act (DRA) of 2005 included a provision that HHAs 
submit required OASIS data.  The DRA stipulates that an HHAs failure to 
submit data will result in a 2-percent payment reduction to its home health 
market basket index increase for a year.13, 14  CMS works with Medicare 
contractors to identify HHAs that have submitted claims but have not 
transmitted any OASIS data.  The contractors notify any such HHAs in 
writing, and those HHAs have 30 days to dispute the reduced payment.  
During this time, an HHA disputing the reduction must submit 
documentation to confirm that it did transmit the data.  If CMS upholds 
the decision, the contractor programs the payment system to apply a        
2-percent payment reduction to that HHAs market basket index increase 
for the upcoming calendar year.15 
As of January 1, 2010, CMS required HHAs to submit OASIS data as a 
Medicare condition for payment in addition to a CoP.  Since that date, all 
HHAs must submit OASIS data before submitting a final claim for 
payment, and the payment codes on the final claim and OASIS submission 
must match.16 
CMS OASIS requirements for States.  CMS delegates overall responsibility 
for OASIS data collection and database management to State agencies.17  
Although CMS regulations specify that State agencies are to establish and 
maintain OASIS databases, States in fact house CMS OASIS servers and 
 
10 42 CFR  484.20.  
11 42 CFR  484.55. 
12 42 CFR  484.20(b). 
13 DRA of 2005, P. L. 109-171,  5201(c)(2) (February 8, 2006) (adding Social Security Act  
1895(b)(3)(B)(v)). 
14 The primary source of CMSs market basket index is the Medicare cost reports supplied by providers to 
construct weights of major cost categories.  The market basket reflects price inflation of these cost categories, 
and CMS uses the weights to update payments and cost limits of various CMS payment systems.    
15 CMS, Medicare Claims Processing Manual,  Pub. No. 100-04, ch. 10,  120. 
16 74 Fed. Reg. 58078, 58111 (Nov. 10, 2009) (revising 42 CFR  484.210(e) and 484.250). 
17 42 CFR  488.68. 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  3 
   
do not create their own databases.18  Additional State agencies 
responsibilities for operating the OASIS submission system include: 
  analyzing and editing OASIS data,19 
  ensuring accuracy of OASIS data,20 
  restricting access to OASIS data,21 and 
  providing training and technical support for HHAs.22 
CMS offers States agencies no guidance or details on their responsibilities 
for operating the OASIS submission system.  Federal regulations do not 
include specific oversight responsibilities for CMS with respect to OASIS 
data.  CMS oversees State agencies survey competence through annual 
reviews of States performance as measured by standards that CMS 
establishes.23  
METHODOLOGY 
Scope 
This evaluation determined whether HHAs and States met Federal reporting 
requirements for OASIS data in 2009.  It also determined the extent to which 
CMS oversaw the accuracy and completeness of OASIS data that HHAs 
submitted.  We reviewed the extent to which CMS instituted the 2-percent 
payment reduction for HHAs that failed to submit data since the DRA 
provision went into effect in 2007.  We analyzed HHAs that CMS penalized 
with a 2-percent payment reduction from 2007 to 2010 and documented any 
HHAs that CMS similarly penalized in multiple years.  Finally, we 
calculated how many claims from 2009 had a corresponding OASIS data 
submission to a State agency.  We limited our analysis to Medicare patients 
for this evaluation.  This evaluation also did not determine the extent to 
which OASIS data submitted by HHAs accurately reflected patients 
conditions at the time of assessments.   
Data Sources 
We used the following five data sources to analyze the OASIS data that 
HHAs submitted:  (1) an online survey of State officials, (2) the National 
Claims History File (NCH), (3) OASIS data, (4) structured interviews with 
 
18 42 CFR  488.68(a). 
19 42 CFR  488.68(b). 
20 42 CFR  488.68(c). 
21 42 CFR  488.68(d). 
22 42 CFR  488.68(e). 
23 CMS, Quality Assurance for the Medicare and Medicaid Programs:  Fiscal Year 2011 Mission and Priority 
Document, pp. 2122, revised October 15, 2010. 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  4 
   
CMS staff, and (5) CMS data identifying HHAs that were penalized with the       
2-percent payment reduction between 2007 and 2010.   
Survey of States.  We surveyed all 50 States and the District of Columbia 
(States) in May 2011 about their efforts to fulfill their oversight 
responsibilities for OASIS data.  The survey focused on States policies and 
procedures for ensuring the accuracy and completeness of OASIS data that 
HHAs submitted.  We sent the survey to the States OASIS Automation 
Coordinators as indentified on the CMS Web site.  We had a 98-percent 
response rate; only the District of Columbia failed to respond.  
NCH and OASIS data.  We obtained all 6,633,582 home health Part A claims 
from 2009 to determine the number of OASIS records that HHAs should 
have submitted.  We linked those claims to the submitted OASIS records 
from the same period to determine which claims were missing required 
OASIS records in 2009.  
In addition, we reviewed the OASIS records to determine whether HHAs 
submitted the data within 30 days from the patient assessment date, as 
required. 
Interviews with CMS staff.  We conducted structured interviews with CMS 
officials knowledgeable about the OASIS database and data validation 
procedures in the Center for Medicaid, CHIP, and Survey and Certification 
as well as from the Office of Clinical Standards and Quality.  We also 
interviewed staff working in claims processing and asked how CMS 
implements the 2-percent payment reduction for failure to submit OASIS 
data. 
CMS data on HHAs penalized with the 2-percent payment reduction.  We 
obtained a list from CMS of all HHAs that it penalized with the 2-percent 
payment reduction in 2007, 2008, 2009, and 2010 for failure to submit the 
required OASIS data.  We analyzed the data to determine the trend of          
2-percent payment reductions and calculated how many HHAs CMS 
repeatedly penalized between 2007 and 2010. 
Limitations 
We did not analyze the completeness or accuracy of OASIS data submitted 
for individual patients.  
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  5 
   
FINDINGS 
Home health agencies did not meet all Federal 
reporting requirements for OASIS data  
Our analysis found that HHAs were deficient in meeting two Federal 
reporting requirements for OASIS data:  that HHAs submit OASIS data for 
all Medicare beneficiaries they serve and that they submit them within       
30 days from the date of the patient assessment. 
HHAs did not submit required OASIS data for 6 percent of claims 
in 2009, which represented over $1 billion in Medicare payments 
In 2009, 392,180 (6 percent) Medicare home health claims submitted by 
HHAs did not have OASIS data for the same period.  Although the missing 
OASIS data account for over $1 billion in Medicare payments, submitting 
OASIS data did not become a Medicare condition of payment until January 
1, 2010.  This means that for 2009 these claims were not paid in error.  
Furthermore, in 2009, 85 percent of HHAs did not submit OASIS data for at 
least one claim.  Over half of those HHAs did not submit OASIS data for at 
least 10 claims in 2009. (See Table 1.) 
 
Table 1:  Distribution of HHAs With Claims Missing OASIS Data, 2009 
 
Number of Claims per HHA  Number of HHAs Missing Claims  Percentage of HHAs 
 
15  2,106  23% 
610  1,369  15% 
1120  1,787  19% 
2140  1,718  19% 
41100  1,521  16% 
101 or more  773  8% 
     Total  9,274  100% 
 
Source:  NCH and OASIS data, 2009.
 
From 2007 through 2010, CMS penalized only 199 HHAs by assessing the 
2-percent payment reduction for not submitting OASIS data (see Table 2).  
Among these HHAs, CMS penalized 13 for 2 of the 4 years reviewed, and 
CMS penalized 1 for 3 consecutive years. 
 
 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  6 
   
Table 2:  HHAs CMS Penalized With a 2-Percent Payment Reduction, 20072010 
2009 
  2007  2008  2010 
 
HHAs with 2-percent payment 
41  62  36  60 
reduction 
Total HHAs  9.404  10,036  10,961  11,488 
Percentage of total HHAs  0.4%  0.6%  0.3%  0.5% 
Source:  CMS 2-percent payment reduction data, 20072010. 
 
The small number of HHAs penalized may be explained, in part, by CMSs 
failure to verify the completeness of OASIS data submitted.   CMS officials 
told us that it penalizes only those HHAs that failed to submit any OASIS 
data for that year.  An HHA needs to submit only one OASIS out of 
potentially hundreds or thousands during the yearlong reporting period to 
avoid the 2-percent payment penalty.   
HHAs submitted 15 percent of OASIS datasets late 
CMS does not penalize HHAs for late submissions.  In 2009, HHAs 
submitted 15 percent of OASIS datasets after the required 30-day timeframe 
(see Table 3).24  HHAs submitted almost a million OASIS (962,646) datasets 
late; about a third of those (342,936) were more than 21 days late.  
 
Table 3:  Timeliness of HHA OASIS Submissions, 2009 
 
  Number of Submissions  Percentage of Total Submissions 
 
Within 30 days  5,278,756  85% 
1 to 10 days late  423,068  7% 
11 to 20 days late  196,642  3% 
21 to 30 days late  101,548  2% 
31 to 60 days late  140,096  2% 
61 days or more late  101,292  2% 
     Total OASIS submissions  6,241,402  100%* 
Source:  NCH and OASIS data, 2009. 
*Does not equal 100 percent because of rounding. 
 
24 Our analysis calculated the number of days between assessment date and OASIS submission.  Our analysis 
does not account for HHAs that may have resubmitted a previously rejected OASIS.  The date of submission 
reflects the most current rather than the first submission by the HHA. 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  7 
   
States met some, but not all, OASIS requirements 
Our survey of States showed that they provided training and support for 
OASIS and that most restricted access to the data.  However, they conducted 
limited data analysis or review of the datas accuracy.  
Some States provided training and technical support to HHAs, and 
almost all restricted access to OASIS data 
According to our survey results, 30 States provided OASIS training to 
HHAs, and 45 States provided OASIS technical support to HHAs in the     
12 months before our survey was sent in May 2011 (see Table 4).   
 
Table 4:  OASIS Training Topics Covered 
  Number of States Covering This Topic 
Administering the OASIS dataset  22 
Transmitting OASIS data  21 
Integrating the OASIS dataset into the HHAs recordkeeping  17 
Ensuring privacy and confidentiality of the OASIS dataset  14 
Using software to encode OASIS data  14 
Transitioning to the latest OASIS reporting requirements   5 
Using regulatory resources and guidance  5 
Coding accurately   3 
  
Source:  OIG survey of States, 2011.
 
Also, according to our survey results, almost all States (49) had policies and 
procedures to restrict access to OASIS data.  Almost all kept the CMS 
OASIS server in a secure room (47 States), protected the data with a 
password (43), and followed encryption standards (43). 
States conducted limited data analysis and review of the accuracy 
of OASIS data  
States analyses of OASIS data were generally limited to CMSs automated 
OASIS submission system.  Forty-seven States reported that they did 
nothing beyond CMS automated checks.  Only three States reported that 
they further validated data by checking for missing data and reconciling 
duplicate patients.  No States reported conducting analyses to ensure that the 
OASIS data accurately reflected patients conditions at the time of 
assessments.    
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  8 
   
Furthermore, States took little action when they identified problems with 
OASIS reporting.  States most commonly responded that they contacted 
HHAs when they identified problems with submissions or quality; however, 
three States indicated that they did not take any action.  Few States 
responded that they took formal action to address OASIS data problems.  
For example, four States initiated a quality improvement plan for HHAs, and 
three States scheduled training for HHAs with OASIS reporting problems.   
Twenty-three States reported that they informed the State surveyors about 
HHAs with OASIS reporting problems.  State surveyors have the authority 
to inspect HHAs for compliance with the Medicare CoPs and to cite 
deficiencies when HHAs do not meet those standards.  However, Federal 
law requires State surveyors to inspect HHAs only once every 36 months.  
CMS did not ensure the accuracy or completeness of 
OASIS data 
Federal regulations do not specify oversight responsibilities for CMS with 
respect to OASIS data accuracy or completeness, and we found little 
evidence that CMS reviewed or validated OASIS data nationally.  In 
addition, CMS did not review States protocols or procedures for collecting 
OASIS data from HHAs. 
CMS did not review OASIS data collected by States for accuracy or 
completeness 
CMS has direct access to OASIS data in the national database; however, our 
interviews with CMS staff revealed that CMS did not access, review, edit, or 
validate OASIS data nationally.  In responses to our survey, only four States 
reported that CMS had requested information or reviewed OASIS data in the 
last 12 months; only two States reported that CMS requested a specific 
analysis of OASIS data in the 12 months before our survey was sent in May 
2011.  Those requests addressed reviewing data transmissions and 
administering the 2-percent payment reduction.   
CMS did not validate States processes for monitoring submitted 
OASIS data 
Twenty States reported that CMS had never reviewed their States protocols 
or procedures for collecting OASIS data from HHAs.  Twenty-four States 
could not say whether CMS had ever reviewed their OASIS data collection 
procedures.  In our interviews, CMS staff told us that CMS provided no 
guidance to States on establishing procedures for submitting and validating 
OASIS data.  CMS also stated that it did not specifically advise States to 
monitor the timeliness or validity of OASIS data submissions.  
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  9 
   
RECOMMENDATIONS 
OASIS data are the basis of Medicare reimbursement, and inaccurate or 
missing data could indicate potential Medicare fraud.  If HHAs submit 
inaccurate information, they could be reimbursed for services they did not 
deliver to beneficiaries.  OASIS errors also undermine the integrity of the 
home health quality measures, potentially affecting the Home Health 
Compare Web site on which beneficiaries and their families rely.  In 2009, 
States and HHAs did not meet all Federal reporting requirements for OASIS 
data.  HHAs did not submit OASIS data for 6 percent of claims representing 
over $1 billion in Medicare payments, and they submitted 15 percent of 
OASIS data late.   
Congress and CMS established a financial disincentive for HHAs failure to 
submit OASIS data; however, at the time of our review, CMS had not 
imposed the 2-percent payment reduction on the market basket index 
increase on all HHAs that did not submit all required OASIS datasets, which 
may have minimized its effect.   
Our review also found that most States did not perform additional data 
validation beyond the steps in the automated CMS OASIS submission 
system.  No States had systems to ensure that submitted OASIS data 
accurately reflected the patients conditions at the time of assessments. 
In light of our findings, we recommend that CMS: 
Identify all HHAs that failed to submit OASIS data and apply the    
2-percent payment reduction to them  
Our analysis showed that many HHAs did not submit OASIS data according 
to Federal reporting requirements, yet CMS penalized only a small number 
with the 2-percent payment reduction.  CMS considers HHAs to be in 
compliance if they submit at least one OASIS regardless of how many they 
completed. 
In 2010, CMS began requiring HHAs to submit OASIS data before the final 
claim as a condition for payment.  When CMS fully implements this 
condition, the 2-percent penalty may become unnecessary.  Until that time, 
CMS should raise the threshold for compliance to deter other HHAs from 
failing to comply with this important requirement. 
Establish and implement enforcement actions for HHAs that 
submit OASIS data after the 30-day deadline 
CMS does not penalize HHAs for submitting OASIS data late.  In addition, 
HHAs lack an incentive to submit the OASIS before final claims, which they 
can submit as long as 3 to 4 weeks after the OASIS data are due.  CMS 
should identify HHAs that are consistently or egregiously late in submitting 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  10 
   
data.  CMS should also consider enforcement actions for HHAs that 
consistently miss the 30-day deadline.  
Develop clear guidelines that delineate expectations for States 
regarding timely and accurate OASIS data 
CMS holds States accountable for ensuring that HHAs submit timely and 
accurate OASIS data; however, it does not provide guidance on how States 
oversee this process.  In addition to reviewing HHAs as part of the 3-year 
survey cycle, CMS should evaluate all States protocols and procedures for 
analyzing and editing OASIS data to find vulnerabilities and highlight best 
practices.  
CMS should also develop guidelines to ensure data accuracy.  OASIS data 
have multiple uses, from reimbursement to quality measures, yet the current 
system uses self-reported data from HHAs with little to no validation.  CMS 
should work with States to develop procedures that can detect both data 
input errors and willful misrepresentation of patients conditions at the time 
of assessments. 
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
In its comments on the draft report, CMS concurred with our first 
recommendation, but it did not concur with our second and third 
recommendations.  CMS noted that it had implemented measures to 
improve oversight of States and HHAs and to address accuracy and 
completeness of the OASIS data process.  
CMS concurred with our first recommendation stating that it is pursuing a 
plan of action consistent with our recommendation.  It is exploring 
methods to increase the compliance threshold for the 2-percent payment 
reduction.  In addition, CMS is working to link the Medicare claims 
processing system and the State OASIS repositories to deny payment to 
HHAs that fail to submit OASIS data. 
CMS did not concur with our second recommendation.  CMS stated that 
our findings failed to note that the error code for late submissions also 
included corrected OASIS data submissions.  CMS also noted that the 
survey process looks at OASIS data submissions and targets late 
submissions.  CMS added that it will revise the worksheet surveyors 
complete before starting the survey to emphasize the error for late OASIS 
submissions.  We understand that CMS uses the survey process to review 
OASIS data submissions for timeliness and accuracy.  However, CMS 
requires State agencies to survey HHAs only once every 3 years.  
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  11 
   
Although this survey cycle may be sufficient for other purposes, it could 
be inadequate to review timeliness of OASIS data.  Rather than relying 
solely on the survey process, CMS could, for example, analyze data in the 
OASIS repository to identify HHAs that consistently submit OASIS data 
late. 
CMS also did not concur with our third recommendation.  CMS stated that 
our report failed to identify the magnitude of costs associated with additional 
workload on State agencies to monitor error messages.  It also noted that 
identifying willful misrepresentation of data is outside the scope of the 
States technical ability.  We remain concerned that the current system relies 
on self-reported data from the HHAs without further validation.  Finally, 
CMS stated that the findings do not support the significant investment that 
would be required to modify the survey process.  We understand the 
constraints of the survey process and are aware of resources required to 
modify it.  In our recommendation, we did not intend for CMS to modify the 
survey process.  CMS should work with States outside the survey process 
and develop guidelines that States could follow to improve the quality and 
accuracy of OASIS data.  Based on CMSs comments, we clarified the 
wording of this recommendation.   
See the Appendix for the full text of CMSs comments. 
 
OEI-01-10-00460   Limited Oversight of Home Health Agency OASIS Data  12 
  APPENDIX A 
Agency Comments 
,. y~' iI:.\'l(~. f{\f 
~
(  OEPARlMENT OF HEALTH & HUMAN SERVICES  Cent"rs for Medicare & Medicaid Services
<5~ 
Administrator 
Washington, DC 20201 
DATE: 	 OEC  1 4 2011 
TO: 	 Daniel R. Levinson 

InspectoI General 

FROM: 	 MaJilyn ta\eimer 

Acting Admfuistrator 

SUBJECT: 	 Office of Inspector General (OIG) Draft Report:  Limited Oversight of 
Home Health Agency OASIS Data (OEI-OI-1O-00460) 
Thank you for the opportunity to review and comment on the subject OIG draft report. 
The Centers for Medicare & Medicaid Services (CMS) appreciates the contributions and 
valuable input by the OIG in reviewing the oversight ofCMS activities to assess the 
collection ofOASIS data. The purpose of this report was to determine the--(l) Extent to 
which Medicare home health agencies (HHAs) meet Federal reporting requirements for 
the Outcome and Assessment Information Set (OASIS) data; (2) Extent to which States 
meet Federal reporting requirements for OASIS data; and (3) Extent to which CMS 
oversees the accuracy and completeness of OASIS data submitted by HHAs. 
Since the implementation of OASIS in 1999, CMS has implemented a number of 
measures to improve the oversight of States and HHAs, and some of those measures also 
address accuracy and completeness ofthe OASIS data process. For instance-
 	 Beginning January 1,2010, HHAs were required to submit an OASIS as a 
condition for payment. To ensure compliance with OASIS data submission as a 
condition of payment, HHAs must submit OASIS start ofcare and reCertification 
assessment data to the State prior to submitting final Medicare claims. 
Furthermore, HHAs must ensure that the Health Insurance Prospective Payment 
System (HIPPS) code on the final claim matches that received on the OASIS 
validation report; 
 	 We instructed surveyors to address late OASIS submissions as part of the pre
survey process. The HHA surveyor worksheet targets HHAs with a 20-percent 
late submission rate for investigation; 
 	 Currently, the transmission ofassessment data to the OASIS Submission System 
and transmission ofHIPPS codes on claims to Medicare contractors are entirely 
separate processes. The Fiscal Intermediary Shared System (FISS) does not have 
access to the OASIS Submission System. The payment group determined from 
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ACKNOWLEDGMENTS 
This report was prepared under the direction of Joyce Greenleaf, Regional 
Inspector General for Evaluation and Inspections in the Boston regional 
office, and Russell Hereford, Deputy Regional Inspector General.   
Danielle Fletcher served as the team leader for this study.  Other principal 
Office of Evaluation and Inspections staff from the Boston regional office 
who contributed to the report include Tim Chettiath and Kim Yates; central 
office staff who contributed includes Sandy Khoury. 
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Office of Inspector General 
http://oig.hhs.gov 
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is 
to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the 
health and welfare of beneficiaries served by those programs.  This statutory mission is carried out through 
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connection with these cases, OCIG also negotiates and monitors corporate integrity agreements.  OCIG 
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