A year and a half after the Centers for Medicare & Medicaid Services began auditing thousands of nursing homes for inappropriate schizophrenia diagnoses, providers are raising concerns that the quality stars they lost aren’t being restored as promised.

The issue arose Tuesday afternoon during a SNF Open Door Forum conference call that CMS hosted, ostensibly to discuss the agency’s fiscal 2025 skilled nursing pay rule finalized last week. Callers had few questions about the rule, but a single inquiry about suppressed star ratings led to a rolling tide of comments about the schizophrenia audits’ ongoing impact.

According to a memo issued when CMS launched the program, facilities found to have related coding inaccuracies in their MDS records would have their overall Quality Measure rating and long-stay QM rating downgraded to one star for six months (which would also bring a facility’s overall star rating down by one star). The agency also said it would suppress affected providers’ short-stay QM ratings for six months and their long-stay antipsychotic QM for 12 months.

But one caller whose organization was found out of compliance during an early audit reported that she had yet to see the penalty reversed after a year, despite repeated attempts to talk with CMS about what more needed to be done.

“We immediately at the time last year corrected everything that came up on the report,” the unidentified caller said. “I need to get in touch with someone that can look at this.  We were told it would be for a year.  It’s now over a year. Our QMs are still a 1. … We were a 5-star facility in QM. We became a one.  It is hurting us terribly.”   

The provider said she had used several CMS mailboxes only to be repeatedly told the same thing by staff: that the agency had to review its case and see if the provider actually made corrections.

“This was done already last year,” she repeated on the call. “Who is responsible to look at this?”

Evan Shulman, director of the Division of Nursing Homes, said CMS did not automatically reverse affected star-ratings “based on a timeframe.”

“We still do monitor facilities’ data after audits,” he said. “We will at times do a re-audit to ensure that the facility corrected what was identified during the audit. … We monitor the data to see the changes we expect based on the findings from the original audit.”

That language echoes details included in the January 2023 memo.

“For all facilities where patterns of coding inaccuracies were identified, either through an audit or through a facility’s admission, CMS will monitor each audited facility’s data to identify if the information indicates they have addressed the identified issues, and if any downgrades or suppressions that are applied should be lifted at the timeframes indicated above,” it said.

But that leaves providers in limbo if they can’t get a clear answer as to whether they’ve done everything needed to proceed.

Mary Gracey-White of the Greater New York Health Care Facilities Association said she had also previously been in touch with CMS, trying to get clarification on how providers can exit the penalty stage.

“We do get many questions from facilities in our association regarding restoration of the stars,”  she said.

Reached after the call, Zimmet Healthcare Services Group’s Alicia Cantinieri told McKnight’s Long-Term Care News that CMS is now conducting schizophrenia audits of facilities that did not receive a letter in the initial investigation period in 2023.

“This has not gone away,” she said, noting other frustrations providers have expressed about the targeted program. “We’ve also heard from clients that when they opted out, they received the same penalty as if they had failed. CMS has also sent letters to facilities that did previously opt out to recheck them, and those did not have the option to opt out.”

Still, some providers are exiting the penalty phase — though they may not know it right away. Cantinieri said Zimmet had one client who had failed the audit whose Five-Star  penalty was lifted after six months. They were not notified, but the change appeared when they ran a periodic report. 

On a related note, Pete Van Runkle, executive director of the Ohio Health Care Association, said on the CMS call that a change that suppressed antipsychotic measures for prior quarters was affecting providers in his state in unintended ways.

“What I have seen in the CMS data tables … is that once that suppression happens, it goes backward before the audit was conducted for several quarters,” he told Shulman. “While that may not affect star ratings going forward, we in Ohio use the antipsychotic measure as one of our quality measures for Medicaid purposes for reimbursement. So that sort of retroactive suppression of data can be very harmful in that context.”

Shulman said he was unaware that CMS had the capacity to suppress ratings retroactively and pledged to “take a look” at that specific issue. Several states are using a nursing home’s rate of antipsychotic use as a quality benchmark on which incentive payments can be based.