Once again, CMS is proposing to change the Point Scoring Variables of the OASIS for 2016.  This is an issue that I do have some concerns about, but as a financial person that is not clinically trained I do not feel that I am able to understand and address with the level of expertise necessary.

2016 would be the third year in a row that we have had different Point Values assigned to the various Point Scoring Variables for establishing the Clinical and Functional Domains for a Medicare patient.  These are important because they establish the patient’s acuity level which determines the reimbursement for that episode.

What a # of agencies identified for CY 2015 was that many like-kind patients (those that had OASIS responses similar or exact for CY 2014 & CY 2015) were being scored at a lower Clinical and/or Functional Dimension in CY 2015, and as such had much lower reimbursement rates for those patients.  There is the potential here for CMS to ‘game’ reimbursement by the way that they adjust/manipulate the:

  • Point Scoring Variables of the OASIS (which they propose in this Rule to adjust every year now) and
  • Case-Mix Points  (which they also propose in this Rule to adjust every year)


Note: I am not saying that they do (or did) game reimbursement, just that this would be an area that they very easily could and few (if any) would even notice/identify this as the reason.  But I wanted to make this comment because CMS has been saying for years that we as an industry game reimbursement to artificially increase reimbursement; and to the extreme levels that they identify this gaming to be, it MUST be an industry-wide activity because a handful of (meaning several hundred {or even a few thousand}) HHAs would NOT be able to cause the impact that CMS accuses us of!

  • See the proposed adjustment regarding the ‘Nominal Change in the Case-Mix Weights’ ,     § III B 2 of the Proposed Rule (pgs 39856-857)
    • This adjustment is proposed for 2016 AND 2017 and is projected to reduce reimbursement to the HH industry by $300 million (-1.72%) for 2016!


From the 2016 Proposed Rule (see pg 39850, near bottom of Column 2):

For CY 2015, we finalized a policy to annually recalibrate the HH PPS casemix weights—adjusting the weights relative to one another—using the most current, complete data available.”


2016 would be the 2nd year in a row that they changed/reduced (more) these values and it is these values that when tied together establish a Case-Mix Weight, and as such Reimbursement for the episode.

Analyzing these changes from a ‘patient-need‘ and ‘adequate presentation of the patient’s true condition’ is not something I am trained for. I can show the changes from 2012 to 2015, and from 2015 to 2016 (Proposed), etc…, so that shows the points capable to be earned in the Clinical and Functional Domains (and I have that in excel), but I cannot evaluate it from the perspective of how reasonable this will represent the patient.

I was contacted by a # of HHAs earlier this year because they noted a drop in their reimbursement (much more than the 0.3% reduction noted in the FINAL Rule for 2015) and yet they had the same type of patient from 2014 to 2015. There were a few things that could affect this, such as:

  • a change in the service area’s Wage-Index (i.e., the relative cost of labor)
  • the change in the 60-day rate and the
  • the change in the Clinical and Functional Scoring Domains (this was the issue that caused the largest impact and they did not realize this until contacting me as there was little discussion about this change anywhere that I was aware of)


My conjecture is that a great many HHAs would see that a significant portion of the reduction to their reimbursement in 2015 was directly applicable to this issue (and it looks to be applicable again in 2016 unless the industry stands up and does somenting about it: i.e., send in comments to the Proposed Rule, but we only have until 5:00pm ET on Sept 4, 2015). Do this simple test:

  • Pull a sample of client charts from 2014 and note the following:
    • what the Scores were for the Clinical and Functional Domains per the Original OASIS
    • what the Case-Mix Weight was per the Original OASIS and
    • what the Reimbursement was per the Original OASIS


  • Now, run that same 2014 patient/OASIS information into your OASIS software for 2015 so you can compare to:
    • what the Clinical and Functional Domain Scores are
    • what the Case-Mix Weight for that episode is now and
    • what the Reimbursement is now


I believe that you will find that for certain-type patients, your 2015 Scores; Case-Mix Weight and Reimbursement will be quite different; more often than not culminating in reductions to your episodic reimbursement; sometimes very significantly so!

  • Much more than would have been expected when accounting for the -0.3% reduction projected nationally and for the change in your service area(s) Wage-Index!


Therefore, my concern is that CMS may indeed be ‘gaming‘ the Point Scoring Variables and by default the Case-Mix Points and this may be a way for them to backdoor a reduction to our reimbursement that most would never identify.  What CMS is doing  may be legitimate, but I am not one to take it on faith, especially faith in an entity that has treated our industry with such disdain over the last 10+ years.  And I for one, would feel much more comfortable if some clinicians/therapists reviewed and opined on this issue as to whether or not what CMS is doing here is reasonable.

I have created a spreadsheet that I am making available to anyone that wants it, and this spreadsheet is the Points for each of the Scoring Variables (i.e., the 51 OASIS questions/responses) for CY 2014, CY 2015 and Proposed for CY 2016.  At the bottom of this spreadsheet it also identifies the points required for any given Clinical and Functional level.  Hopefully, this spreadsheet in the hands of those that understand spreadsheets and the concept of patient-acuity levels can make some sense of this CMS proposal and inform the industry of the reasonableness or lack thereof  of this issue in the Proposed Rule.

Link:  Clinical & Functional Point Scoring Variables

On pg 39852 (bottom portion of Column 1) of the Federal Register, CMS identifies the following:

The CY 2016 four-equation model resulted in 130 point-giving variables being used in the model (as compared to the 124 variables for the 2015 recalibration). There were nine variables that were added to the model and three variables that were dropped from the model due to the absence of additional resources associated with the variable. The points for 18 variables increased in the CY 2016 four-equation model and the points for 43 variables decreased in the CY 2016 4-equation model. There were 58 variables with the same point values.

  • As a FYI: there are a potential 204 Point Scoring Variables for any given year

Changes in the Scoring Variables used per my review (see spreadsheet):

  • 2012-2014  158
  •   CY 2015    120
  •   CY 2016   126 (per Proposed Rule)


I hesitate to comment too much more on this as I do not want to bias anyone that might review this for reasonableness.


Additionally, a couple of points to consider:

  1. Does CMS’s belief that they need to change these every year now (historically they updated them every 3-5 years) indicate that they do not have such a good handle/control of HH PPS ?  and
  2. Is there any possibility that CMS’ adjusting these values over the years may have had an impact in the increase they identify in the Case-Mix Weights to justify their ‘Nominal Change in the Case-Mix Weight’ adjustment?

I am not sure, just putting it out there.