by editor | Jan 29, 2023 | Human Resources, Interdisciplinary Team
Maslow’s hierarchy of needs is a theory that can be used to provide leaders and organizations with guidance on how to motivate employees. But what is this hierarchy and what is Maslow’s theory?
What is Maslow’s Hierarchy of Needs?
Maslow developed his theory on the Hierarchy of Needs in the 1940s. The hierarchy suggests that people are first motivated to fulfill basic needs before they move on to more advanced needs.
The theory states that there are five fundamental human needs that can be represented as a pyramid. Each of the five needs builds on the prior need. Individuals want to meet needs at a lower level before progressing to needs at a higher level.
The highest-level need in Maslow’s hierarchy is self-actualization, where an individual achieves self-fulfillment.
How does Maslow’s Hierarchy of Needs relate to leadership?
A good manager understands this hierarchy of needs and leads his team so that he is meeting each employee at the employee’s current level of need while simultaneously encouraging the employee to continue to move up the pyramid so that the employee eventually achieves self-actualization. In the workplace, self-actualization translates to an employee’s desire to maximize his potential at work.
What are the levels of the hierarchy?
In Maslow’s hierarchy, Level 5 is the lowest level and Level 1 is the highest level. An individual or employee will start at a lower level and move up levels as he tries to achieve the highest level in the hierarchy.
Level 5: Psychological needs – survival
This is a most basic need for survival. Employees at this level want to feel secure that they have a steady income.
Level 4: Safety and security
Managers and leaders need to make employees feel secure. Some managers do not realize this and think that employees will work harder if they are “kept on their toes.” But this strategy usually fails. Rather than working harder, employees become obsessed with job security.
- How can a leader make employees feel secure?
- Communication: Share the big picture with employees.
- Clear rules: Employees should know where they stand at all times
- Be supportive: Support employees if they are struggling or if they fail
- Be consistent: Be the same every day
- Be fair
Level 3: Belonging (social needs)
Employees enjoy a team environment and a social workplace.
- How can a leader create a social environment and a feeling of belonging?
- Conduct team meetings
- Create an area where people can gather, e.g., for coffee
- Encourage a feeling that people are a part of the team
- Organize social events outside of work
Level 2: Esteem/status
Employees want to be noticed, on occasion, and to stand out for their accomplishments and for what they do better than others. People like to feel important, occasionally.
- How can a leader meet this need of employees to feel important?
- Give employees regular recognition
- Spend time with employees
Level 1: Self actualization
Self-actualization is maximizing an self-fulfillment where an individual discovers his potential and uses his skills to the utmost. This is the highest level of Maslow’s hierarchy, where employees are maximizing their potential at work.
- How can a leader help employees maximize their potential?
- Give employees ownership of tasks or projects
- Empower employees
- Help employees find ways to advance in their careers
What defines a great organization?
Maslow believes that in a great organization, employees will be at the level of self-actualization. That is, all employees must achieve Level 1. For employees to achieve Level 1, leadership must support employees through all the lower levels of the hierarchy. The pyramid will crumble if employees are lacking the supporting levels.
Further, leadership must make it possible for employees to achieve self-actualization. Employees need to be trained, to acquire new skills, and to have an environment where they gain a sense of satisfaction. A good leader will learn his employees’ potential and create an environment where people are trusted, can flourish, and are given important tasks to complete. A good leader will create an environment where employees can achieve self-actualization.
Where can you find more information?
by editor | Jan 29, 2023 | Billing, Documentation - Nurses, Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Office Team, Hospice 101 - Social Workers, Intake, Rules and Regulations - Nurses, Rules and Regulations - Office Team
What is the False Claims Act?
The False Claims Act (FCA) was established in 1863 during the Civil War to combat fraud and abuse perpetrated by suppliers of the federal government. At that time, the law was referred to as “Lincoln’s Law.”
The FCA has evolved significantly in recent years and is now one of the main tools used by the government to fight fraud. The FCA penalizes individuals or entities that submit fraudulent claims to the government, cause fraudulent claims to be submitted, or conspire to submit fraudulent claims.
One of the noteworthy provisions of the FCA is the qui tam provision, also known as the whistleblower provision. The qui tam provision allows private citizens, also referred to as “relators”, to report details of alleged fraud to the government. The whistleblower “stands in the shoes” of the government to prosecute the claim. This action benefits the government and the taxpayer as well as potentially the relator, who may receive a share of what is recovered.
How does the FCA relate to a hospice agency?
The False Claims Act allows hospice agency employees, patients, families of patients, or any individuals with alleged knowledge of fraud or abuse by the agency to report the behavior. Under the qui tam provision of the FCA, the relator may be entitled to a percentage of recovered funds.
What are different types of false claims?
A claim is a request for money made to the government. A false claim is money that is obtained from the government due to false or fraudulent claims. False claims include claims where the service
- Has not been provided
- Is already included as part of a different claim (i.e., double billing)
- Is not coded correctly
- Is not supported by the patient’s medical record
Claims may also be false and are covered under the FCA if they result from a referral made in violation of the Federal Anti-kickback statue (Stark Law).
The False Claims Act also includes payment from the government based upon false certification.
False claims include claims that the hospice agency should have known were false or fraudulent.
What is a claim that a hospice agency “should have known” is false?
The FCA expressly includes claims that a hospice agency “should have known” were false or fraudulent. “Should have known” means deliberate ignorance or reckless disregard of truth. As such, a hospice agency cannot avoid liability by simply ignoring inaccuracy in their claims. Examples of “should have known” include:
- Ignorance of billing rules, i.e., lack of knowledge of the rules
- Failure to act on consistent trends that are indicative of inaccurate billing
- Failure to act on inaccuracies or system errors identified by outside or internal auditing teams
- Failure to correct inaccurate billing (impacting either past or future claims)
A hospice agency must understand the rules and take proactive measures — such as conducting internal audits within the organization — to ensure compliance and accurate billing.
How can False Claims Act matters be initiated?
There are two ways that FCA matters can be initiated:
- Initiated by the government: When a FCA matter is initiated by the government, this type of matter typically starts with an audit or an investigation by the government. The government would determine that there is a false claim made to it and would initiate a matter, usually by a subpoena or civil investigative demand (CID). The government would issue the CID directly to the hospice agency. CID is a form of subpoena that requires the hospice agency to engage in one-sided discovery. That is, the hospice agency is required to produce documents demanded, respond to interrogatories, and provide sworn oral testimony. However, the hospice agency may not conduct any discovery.
- Qui tam matter: this type of matter is initiated by a whistleblower, also known as a “relator,” typically through the filing of a sealed lawsuit in a federal district court. The hospice agency does not know about the qui tam lawsuit since the lawsuit is initially served on the government. The case remains under seal while it is investigated by the government.
What is the qui tam process?
Qui tam actions are initially filed under seal. That is, only the US Attorney and some members of the Department of Justice (DOJ) have knowledge of and access to documents related to the case. The relator serves the complaint on the government together with a written disclosure of all material evidence.
The purpose of the sealed qui tam action is to allow the DOJ time to evaluate the relator’s allegations and for the DOJ to decide whether it would like to take over primary responsibility for prosecuting the case. If the DOJ decides to take over primary responsibility for the case, the DOJ is said to “intervene.”
The complaint remains under seal for 60 days during which time the DOJ investigates the relator’s allegations. This 60-day period can be (and typically is) extended. In fact, the government may spend months – or even years – investigating the case.
While the DOJ conducts its investigation, it may issue a Civil Investigative Demand (CID). This form of subpoena requires the defendant (the hospice agency) to engage in one-sided discovery where the hospice agency must produce documents, respond to interrogatories, and provide sworn oral testimony, as demanded. The CID is “one-sided discovery” because the hospice agency may not conduct any discovery.
If the government decides to intervene, the government is then responsible for litigating the case and files its own complaint instead of the complaint that was filed by the relator. The relator remains a party to the complaint.
If the government declines to intervene, the relator may proceed in her own name subject to the government’s right to dismiss the claim or to intervene at a later date.
Whether or not the government decides to intervene, the government remains the real party of interest. (As a reminder, the relator is only “standing in the shoes” of the government.) As such, the government must agree to any decisions on the case. The relator may not agree to dismiss or settle the case without the government’s approval.
What are the key phases in a False Claims Act investigation?
- Phase 1: FCA investigation is triggered. Triggers may include:
- Qui tam (whistleblower) lawsuit
- Call to OIG hotline
- Information identified during audit or claim review
- Complaints
- Data mining
- Phase 2: Formal investigation launches. Investigation may involve:
- Review of corporate filings
- Interview current or former employees
- Review financial records
- Electronic surveillance
- Physical surveillance of employees or of company premises
- DOJ civil investigative demand (CID), or the like
- Government search warrant or raid
- Phase 3: Litigation or resolution
Who are common whistleblowers?
Anyone can be a whistleblower and anyone may report alleged fraudulent activity to the government. The most common relators are:
- Business partners
- Current or former employees
- Competitors
- Patients
- Individuals who mine CMS data to identify anomalies/FCA claims
How can a hospice agency reduce the chance of qui tam lawsuits?
Any complaints or concerns that are raised – by employees, vendors, patients, or competitors, or any other individuals should be investigated and treated with concern as these have the potential to reveal compliance issues that need to be resolved by the hospice agency.
Employee complaints – whether from departing or active employees – are often an excellent source of information on potential compliance issues. A hospice agency should have a clearly established method – that is clearly and often communicated to employees – for employees to raise concerns. It should also have an organized process to diligently investigate and address any concerns raised by employees.
- Internal complaints:
- There must be an organized process – that is communicated regularly to employees – for employees to raise concerns
- All concerns must be investigated
- Have a plan to address any issues that are identified
- Take any necessary corrective actions
- Follow up with the individual who raised the complaint
- Provide training, as needed
- Departing employees
- Treat employees fairly as they leave
- Conduct exit interviews to identify any potential compliance concerns – investigate any issues that may be identified
- Potential releases (e.g., recovery from FCA claims)
Employees must feel that there is a process for raising concerns and that their concerns are heard. Employees should not fear retaliation for raising concerns. A hospice agency should be diligent and careful to respond to all employee complaints that are raised internally or to any complaints that are raised when employees leave the organization.
What are the financial benefits of avoiding FCA violations?
False claims act matters can be quite costly for a hospice organization. In addition to returning the payments associated with the false claims identified and incurring the costs associated with attorney fees to defend the matter, the hospice agency potentially faces the following significant costs:
- Treble damages: The FCA has a treble damages provision which provides that a hospice agency that is found to have violated the FCA statute may be liable to pay three times the amount of the actual false claim amount
- Penalty per claim: Under the FCA, a civil penalty may be assessed for each false claim that is submitted. The civil penalty dollar amount per claim has increased with inflation and currently may be as much as $23,000 per claim.
Where can you find more information?
by editor | Jan 29, 2023 | Compliance and Regulatory - Directors, Metrics and KPIs
Why is data valuable?
Like all other business decisions, a hospice marketing plan must be data driven. More progressive hospice agencies have increasingly begun to understand the value of many types of data in supporting business decisions. This includes internal data such as patient EMR data, financial data including general ledger revenue and expense data (at various levels of aggregation), and quality data. It also includes external data such as publicly available claims data, cost report data, and referral data.
This article published in June 2021 discusses how hospice agencies are using data analysis as a tool to gain an edge over competitors when engaging with potential referral sources. The discussion focuses on use of data analysis to identify which physicians represent referral sources that are more likely to produce (higher quality) referrals. This 2016 NHPCO article discusses the use of hospice metrics as a marketing tool. For example, a hospice agency can share statistics on reduction in hospital admissions for its patients in hospice compared to hospital admissions prior to hospice admission. Other metrics on cost of care or patient satisfaction are of interest, depending upon the referral source.
What data is valuable for designing a marketing strategy?
A hospice should gather data so that it can develop a complete picture of the customers that it serves. It should analyze its patients – including referral sources and patient attributes such as patient diagnosis, length of stay, and patient demographics. Referral sources can be analyzed at different levels of aggregations such as geographic location, facility type, physician type, and physician name. Analysis of hospice patients should be compared to analysis of data for the entire market (in the relevant geographic region). This can help a hospice agency identify where it may have strengths or weaknesses and contribute to its marketing strategy.
Analyze the data: gain input from multiple sources
When analyzing the output of the data analysis, the hospice agency should solicit input from multiple sources in the organization. Combining different perspectives on the data such as input from the executive, marketing, and clinical teams will provide a more holistic view and a more accurate assessment of the current marketing performance and how the go-forward marketing strategy should be designed.
How can the data be analyzed?
The simplest method for analyzing the data is to use Microsoft Excel. Excel is widely used in most organizations, so gaining access to this software should not be difficult. With relatively simple commands, one can analyze data and create charts to visualize the results of data analysis. Another benefit of using Excel for data analysis is that a lot of educational material is available on the Web to answer any questions that you may have about using Excel – in case there are data analysis functions that you want to learn more about.
What other information may be relevant to developing a strategy?
Patient data and claim data are historical data that are important inputs to a developing a marketing strategy. A hospice agency should also analyze forward-looking data as well as more general information such as:
- What are hospice market trends in the geographic region?
- How competitive is the marketplace and are there expectations for change in competition in the near term?
- How well is the role of hospice understood by communities in the geographic region?
- Is the use of hospice accepted by communities in the geographic region?
- Is hospice understood by the medical community in the geographic region?
- What are the demographics of your geographic region and are they expected to change in the near term?
Combining analysis of historical and forward-looking data and soliciting input from team members with different perspectives such as operational, clinical, and marketing will help a hospice agency develop an effective marketing plan.
Where can you find out more?
Using hospice metrics for marketing
by editor | Jan 29, 2023 | Compliance and Regulatory - Directors, Hospice 101 - Aides, Hospice 101 - Chaplain, Hospice 101 - Nurses, Hospice 101 - Office Team, Hospice 101 - Social Workers, QAPI, Regulatory Compliance
What is the governing body?
In accordance with the Conditions of Participation, a Medicare certified hospice agency must have a governing body. The governing body has ultimate responsibility for the hospice agency, including legal and financial authority. Medicare Conditions of Participation require that the governing body is informed of the ongoing activities at the hospice agency, including patient care delivery issues and all QAPI activities. The governing body must also appoint a qualified hospice administrator – a hospice employee with the necessary education and experience – who is responsible for hospice daily operations.
The governing body must meet at least quarterly and must maintain written minutes of its meetings.
There are two Conditions of Participation – 418.100 and 418.58 – that relate to the hospice governing body.
Condition of Participation 418.100
This Condition of Participation defines a standard that the governing body is responsible for management of the hospice agency, including its fiscal operations, provision of services, and continuous quality assessment and performance improvement (QAPI) efforts. The governing body also assumes full legal authority of all hospice operations. It further specifies that the governing body should appoint an administrator that reports to the governing body and who is responsible for hospice agency daily operations. The hospice administrator must be a hospice employee and must have necessary training, education, and experience. CMS does not specify the process by which an administrator should be selected by the governing body. If a hospice agency has multiple locations, the governing body is responsible for administration, supervision, and services for all locations as well as for any arranged services.
Condition of Participation 418.58
This Condition of Participation discusses requirements of a hospice agency’s QAPI program. The governing body must ensure that the hospice agency maintains and implements an ongoing quality improvement and patient safety program. Program performance must be monitored on a regular basis. Further, the governing body must ensure that one or more individuals are selected to lead the organization’s QAPI efforts.
The hospice agency’s organization documents must specify that the hospice governing body is responsible for the QAPI program. Additionally, the governing body specifies the frequency of data collection and level of detail of data collected by the QAPI program.
Are there any state regulations?
State hospice licensure regulations may impose additional requirements on the hospice governing body. They may also have specific requirements on the administrator that is selected by the governing body. A hospice is required to meet the most stringent requirements (whether state or federal).
Surveyors will check that all conditions are met. A hospice agency should maintain evidence of the governing body’s role and activities. Governing body authorizations and activities should be documented in governing body meeting minutes, company organization documents, and company policies and procedures.
Where can you find out more?
CMS Conditions of Participation – Governing Body
by editor | Jan 28, 2023 | Compliance and Regulatory - Directors, Documentation - Nurses, Hospice 101 - Nurses, Metrics and KPIs, Rules and Regulations - Nurses
What is a UPIC?
Unified Program Integrity Contractors (UPICs) are contracted by CMS to conduct detailed medical review, data analysis, and audits of healthcare providers to investigate possibilities of Medicare or Medicaid fraud, waste, and abuse.
While the primary purpose of a RAC or MAC audit is to review payments, the primary purpose of a UPIC audit is to investigate when there is suspicion of fraud – especially fraudulent billing practices. A UPIC audit can lead to federal Medicare fraud charges or criminal prosecution. As such, UPIC audits are more serious than other audits.
What is a UPIC’s scope of responsibility?
Prior to UPICs, Zone Program Integrity Contractors (ZPICs) had been responsible for performing fraud, waste, and abuse detection and prevention activities for CMS. In 2016, CMS began to transition to the UPIC program. This transition took a number of years, with ZPIC contracts rolling over to the UPIC program as ZPIC contracts expired. The ZPIC program has now been phased out and replaced with UPICs. UPICs were formed as part of the Comprehensive Medicaid Integrity Plan (CMIP) with the intention of consolidating under a single federal contractor work performed by numerous Medicare and Medicaid program integrity contractors. UPICs combine all federally funded integrity reviews into a single audit and place payments to all federally funded payers under a higher level of scrutiny.
Consolidating responsibility provides UPICs with access to more data and information about healthcare claims, billing, and payments to hospice agencies. By increasing the level of information and data to which UPICs have access, UPICs have improved ability to identify billing anomalies and fraud.
With respect to regional responsibility, the United States has been split into different geographic jurisdictions: Western, Mid-Western, North-Eastern, South-Eastern, and South-Western. Each UPIC is responsible for handling federal-level audits for both Medicare and Medicaid in one of the different geographic jurisdictions.
How is a hospice agency targeted for a UPIC audit?
UPIC audits are usually triggered by statistical analysis of hospice claims and billing data that identifies anomalies in in a hospice agency’s billing. Factors that often lead to a hospice being targeted for a UPIC audit include:
- Billing trends that are inconsistent with industry trends
- Long inpatient stay
- Referral from law enforcement or a federal agency. (For example, a hospice agency may be referred to a UPIC if at the conclusion of a MAC investigation for improper billing, the findings cannot be classified as billing errors or misunderstandings.)
- Complaints to the OIG
- Inaccurate Medicare billing
- Greater frequency of high end services as compared with local or national averages and patterns
What activities may be involved in a UPIC auditor’s investigation?
UPIC audits are focused reviews. A UPIC will request medical records and conduct interviews to determine whether fraud has occurred.. The UPIC’s audit process typically consists of a detailed review of the hospice’s records to confirm all Medicare billings. A UPIC auditor’s activities may be varied and may extend well beyond a review of medical records and documentation including activities such as:
- On site visit
- Interview hospice patients and/or hospice agency employees
- Review clinical, financial, and time production records
- Perform data analysis
- Look for prior agency violations
How does a UPIC audit progress?
A UPIC audit will typically begin with a letter requesting submission of documents – typically within 30 days but sometimes within 15 days. Most UPICs will agree to an extension of time for document submission.
A hospice agency should carefully review the nature of the request. Is the UPIC only requesting administrative and claims related medical records or is the UPIC also requesting documentation relating to the hospice agency’s business practices?
If the UPIC requests information about the hospice agency’s business practices or business relationships – such as its referral sources – this may indicate that the UPIC received information that the hospice agency is engaged in questionable business practices. If the UPIC identifies improper practices, the hospice agency will be referred to the Office of the Inspector General (OIG) or Department of Justice (DOJ).
If the UPIC only reviews claims and the associated medical or billing records, then there are typically two cases:
- Case 1 – The UPIC requests ten or fewer post-payment claims: the UPIC is likely conducting a “Probe Sample”. The purpose of a probe sample is to check if there are problems with the hospice agency’s billing practices, medical necessity, or documentation. This means that the data analyst identified a potentially problematic pattern following the data analysis. The investigator was notified of this pattern and a sample of claims is requested that match the identified pattern. If no significant problems are identified in the initial sample of claims, the UPIC typically issues an “Education Letter”. If numerous problems are found, the UPIC usually expands its audit and issues a request for a larger sample of 30 or more claims.
- The auditor will extrapolate based upon the findings of the 30 or more claims. Extrapolation allows the auditor to identify the error rate in the sample, and then extrapolate the error rate over the entire universe of six years of claims. (Six years is the maximum look back period for claims review.) For example, if the auditor collects a sample of 50 claims and errors are identified in 10 claims, then the error rate is 10/50=20%. It is then assumed that the accuracy of the billing identified in the sample is indicative of the entire universe. Consequently, the error rate of 20% identified in the sample is applied to the entire universe. Even if the hospice agency changed processes, billing software, or billing staff during the duration of time period of the universe, the sample error rate is still applied to the universe. As such, the impact of extrapolation is often quite significant.
- Case 2 – The UPIC requests 30 or more claims: the UPIC likely selected these claims as part of a “Statistically Relevant Sample” and will extrapolate the error rate that it finds to the entire universe of claims.
UPICs also conduct unannounced office visits to hospice agencies. If an office visit occurs, the UPIC will arrive at the office site with written request for patient medical records. They will also interview patients and hospice agency workers.
What may be the outcome of a UPIC audit?
A UPIC audit may result in payment suspension if there are findings that indicate the existence of overpayment, incorrect billing, or fraud.
When a hospice agency is faced with payment suspension, it may follow the standard Medicare appeals process. Legal counsel may be helpful in guiding a hospice agency regarding rights as applied to recoupment and claims withholding.
Payment suspension sometimes occurs without prior notice to the hospice agency. If the agency receives prior notice, it has 15 days to rebut. The UPIC must respond within 15 days of receiving the rebuttal. CMS then determines if the suspension should be removed. In most cases, the suspension remains in place.
Initial payment suspension can last up to 180 days with two unappealable 180 day extension periods.
A hospice may continue to provide services and submit claims while payments are suspended. During the suspension period, payments are not made to the hospice. Instead, payments are made to an escrow account that is managed by the UPIC.
If overpayments are identified, they are taken from the escrow account. The balance remaining in the escrow account is returned to the hospice agency once the audit is completed.
If the UPIC identifies any fraudulent behavior, the activity is referred to the Department of Justice (DOJ) or to the Office of Inspector General (OIG).
What if a hospice agency disagrees with UPIC findings?
A hospice agency may appeal overpayments identified by the UPIC through the Medicare administrative appeals process.
How can a hospice agency prevent UPIC audits?
By increasing their compliance efforts and activities, hospice agencies can prevent UPICs and decrease the chance of a negative outcome from a UPIC audit. More specifically,
- CMS requires that every hospice agency have a compliance team. In addition, compliance reporting duties must be defined.
- A hospice’s compliance plan must be kept current and should include
- How to update coverage guidelines from CMS
- Billing protocols
- Staff hiring and training on protocols
- Documentation guidelines
- HIPAA information and training
- Protocols for cross checking Medicare and Medicaid claim data
- Hospice compliance teams should conduct periodic and random internal audits of patient records, billing documentation, and required signatures. Compliance teams should look out for persistent errors and indications such as is additional biller training is required – either for the team or for a specific biller? Or, is there a new regulation that the team is not familiar with? Is there a physician who is consistently late with signatures? A clinician whose documentation does not look complete or timely? Charts should be audited randomly but on an ongoing basis and indications of the need for self-disclosure should be followed up on. Self-disclosure results in overpayment, but it typically removes a hospice agency from being a target for UPIC audits since it is an indicator that the hospice conducts internal self-audits and returns overpayments, as necessary.
- Hospice agencies can hire third party auditors to conduct chart and coding audits. These third-party auditors can suggest improvements to billing processes or hospice operations to improve compliance with regulations.
- Track all payer document requests and reimbursement denials; these may help identify billing problems before they are identified by an auditor.
Where can you find out more?
