Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

 

Daniel R. Levinson 

Inspector General

February 2012

OEI-01-10-00460 

LIMITED OVERSIGHT OF 

HOME HEALTH AGENCY 

OASIS DATA
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 
OEI-01-10-00460 Limited Oversight of Home Health Agency OASIS Data 1

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 CMS’s 

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 2

payment covers skilled nursing care, home health aide visits, therapy, 

medical social services, and routine and nonroutine medical supplies 

provided by HHAs.

4

Home Health Quality Measures

 HHAs use the OASIS to determine the payment 

code for each 60-day episode of care they submit for reimbursement. 

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

4 65 Fed. Reg. 41128 (July 3, 2000).

 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 

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 3

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 HHA’s 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 HHA’s 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 CMS’s 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 4

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

• providing training and technical support for HHAs.

and

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. 21–22, revised October 15, 2010.
OEI-01-10-00460 Limited Oversight of Home Health Agency OASIS Data 5

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

In addition, we reviewed the OASIS records to determine whether HHAs 

submitted the data within 30 days from the patient assessment date, as 

required. 

. 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. 

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

Limitations

. 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. 

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 6

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

1–5 2,106 23%

6–10 1,369 15%

11–20 1,787 19%

21–40 1,718 19%

41–100 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 7

Table 2: HHAs CMS Penalized With a 2-Percent Payment Reduction, 2007–2010

2007 2008 2009 2010

HHAs with 2-percent payment 

reduction 41 62 36 60

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, 2007–2010.

The small number of HHAs penalized may be explained, in part, by CMS’s 

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 8

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 data’s 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 CMS’s 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 9

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 10

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 11

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 12

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 CMS’s comments, we clarified the 

wording of this recommendation. 

See the Appendix for the full text of CMS’s comments.
APPENDIX A 

Agency Comments 

. ~'iI:.\'l(~ . ,y f{\f 

Cent"rs for Medicare & Medicaid Services ( OEPARlMENT OF HEALTH & HUMAN 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 of care 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 presurvey process. The HHA surveyor worksheet targets HHAs with a 20-percent 

late submission rate for investigation; 

• 	 Currently, the transmission of assessment 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 

OEI-01-10-00460 Limited Oversight of Home Health Agency OASIS Data 13 
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OEI-01-10-00460 Limited Oversight of Home Health Agency OASIS Data 17
OEI-01-10-00460 Limited Oversight of Home Health Agency OASIS Data 18

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.
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 

a nationwide network of audits, investigations, and inspections conducted by the following operating

components:

Office of Audit Services

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting audits with 

its own audit resources or by overseeing audit work done by others. Audits examine the performance of 

HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are 

intended to provide independent assessments of HHS programs and operations. These assessments help 

reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS.

Office of Evaluation and Inspections

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, 

and the public with timely, useful, and reliable information on significant issues. These evaluations focus 

on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness of 

departmental programs. To promote impact, OEI reports also present practical recommendations for 

improving program operations. 

Office of Investigations

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of fraud and 

misconduct related to HHS programs, operations, and beneficiaries. With investigators working in all 

50 States and the District of Columbia, OI utilizes its resources by actively coordinating with the 

Department of Justice and other Federal, State, and local law enforcement authorities. The investigative 

efforts of OI often lead to criminal convictions, administrative sanctions, and/or civil monetary penalties.

Office of Counsel to the Inspector General

The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering 

advice and opinions on HHS programs and operations and providing all legal support for OIG’s internal 

operations. OCIG represents OIG in all civil and administrative fraud and abuse cases involving HHS 

programs, including False Claims Act, program exclusion, and civil monetary penalty cases. In 

connection with these cases, OCIG also negotiates and monitors corporate integrity agreements. OCIG 

renders advisory opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG enforcement 

authorities.