SO - Health Care Compliance Association

July 200118Editor’s note: MarianneLabahn is Corporate IntegrityCoordinator, at NorthwesternMemorial Hospital. She maybe reached at 312/926-3605or by email at mlabahn@nmh.org.The health care industry isHow tokeep keystaffinformedBy Marianne LabahnAfter reviewing the information,the compliance officemust decide what area(s)need the information andwhether or not the informationrequires action by thearea(s). The informationshould then be sent to thatarea’s manager. In order togoverned by over 30 different governmentalagencies, each of which write ed, one of two methods is used,document that information was provid-rules, regulations, opinions, policies, depending on whether or not the informationrequires action. The informa-and a variety of informational bulletins.The onslaught of information comes in tion can be sent as a Regulatory Updatevarious forms, including advisory opinions,Local Medical Review PoliciesMemo. The process is outlined below.(LMRPs), audit reports, inspection reports,Medicaid notices, notices, rules, If the information being sent requiresInformation-onlyand proposed rules published in the no action, then it can be handled oneFederal Register, fiscal intermediary (FI) of three ways. For information sentnotices, IRS notices, FTC rulings, etc. electronically, the email could be printedand saved to a paper file, saved in anSo, how can compliance departments electronic folder, or both.keep everybody informed about all ofthe new and revised information with For printed information, the Regulatorythe constant influx of data? Even more Update Memo is attached to the printedimportant is being able to prove, if necessary,that the appropriate staff was compliance responsibilities are author-information. Only individuals withgiven information in a timely fashion. ized to use this memo. There may bedepartmental compliance individuals inOne approach is to schedule time daily, key departments who work closely withor at least two to three times per week, the Compliance Office, but do notto visit the appropriate regulatory report directly to it. These individualsWebsites and to gather printed materialsreceived and read the information. they have compliance responsibilities.are authorized to use the memo sinceSome entities, such as the U.S. Departmentof Health and Human ing information:The memorandum includes the follow-Services, provide a free email update ■ To whom the information is beingof postings. There are a variety of other sentsources that can be used for email or ■ The date the information is beingprint notification of news related to sentcompliance issues, including private ■ The statement “The attached copiessources.are reprints of legal/regulatoryupdates and/or information from theMedicare/Medicaid programs(HCFA, the FI’s name, the carriersname, State Department of PublicAid) relating to the area that youoversee. No response is necessary,unless you have questions/concerns.”■ The statement “If you have anyquestions or concerns, please contactme at extension xxx”Both the memo and a copy of theprinted information also are placed in apaper file in the Compliance Office. Ifthe individual sending the informationis not part of the Compliance Office, acopy is sent to the Compliance Officeso it can be maintained in a central fileand easily located if the need arises.Information requiring actionIf the information being sent mightrequire action on the recipient’s part, adifferent process should be followed.email is not used for these. If the noticeof new information was received viaemail, it is printed and follows the sameprocedure as the one for printed material.For printed material, a copy of thematerial is made and attached to theRegulatory Update Memo.In addition to the information listedabove, the memo also should include:■ The statement “Please review theattached and respond by checkingone of the boxes indicated below.Please return to me within twoweeks–with a copy to theCompliance Office.”■ One of the following statementsmust be checked off:❏ The attached information wasreviewed. Due to its content, nofurther action is necessary.