Medicare Compliance & Reimbursement

Seniors could have a much tougher time getting a fair shake at the administrative law judge (ALJ) level if a new proposed rule is finalized.

The Department of Health and Human Services (HHS) wants to compel ALJs and the HHS Departmental Appeals Board (DAB) to follow published guidance issued by HHS or its components -- including the Centers for Medicare & Medicaid Services (CMS).

The proposed rule aims "to ensure that the final administrative decision of the Department reflects the considered opinion of the Secretary of Health and Human Services," according to the Dec. 28 Federal Register.

The rule "would permit the Secretary an opportunity to review DAB [and ALJ] decisions to correct errors in the application of law, or deviations from published guidance, in such disputes," the notice adds.

Speak out: HHS will take comments on the rule until Jan. 28. The rule is at www.access.gpo.gov/su_docs/fedreg/a071228c.html -- scroll down to HHS.

• Providers in Boston, Chicago and their surrounding areas will be the first to participate in CMS' Post Acute Care Payment Reform Demonstration (PAC-PRD). The demo will pilot the CARE patient assessment tool across post-acute provider settings.

The demo will eventually include 10 cities. Boston providers will begin training and data collection in March, while the remaining nine markets will begin on a staggered schedule between May and September. The other sites are Dallas; Lakeland/Tampa, FL; Lincoln, NE; Louisville, KY; Rapid City, SD; Rochester, NY; San Francisco; and Seattle/Tacoma, WA.

The PAC-PRD will allow CMS to collect and compare information about the health of beneficiaries and the care or clinical services they received in various post-acute settings, including home health.

Learn more: Go to http://www.cms.hhs.gov/apps/media/press_releases.asp and scroll down to Dec. 19, 2007, and "CMS Announces Selection of Sites for Demonstration to Revise Post Acute Payment."

• Minnesota is going after Medicaid fraudsters. The state's attorney general's office is investigating St. Paul-based Perfect Home Care Inc. for billing Medicaid for $120,000 worth of personal care assistants when there is no documentation to support the claims.

The state's Medicaid Fraud Control Unit is investigating whether the agency billed for visits never furnished and falsified visit records, according to the St. Paul Pioneer Press.

The AG sought a search warrant for the case, the newspaper notes. The warrant affidavit alleges the agency paid a client's mother $100 for changing her story about lack of services.