Opportunities To Reduce Medicare Payments for Prosthetic Lenses While Enhancing Nationwide Uniformity of Benefits

HRD-85-25: Published: Jan 10, 1985. Publicly Released: Jan 10, 1985.

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GAO discussed two opportunities for reducing the large number of Medicare payments for prosthetic eye lenses after cataract surgery and for ensuring that beneficiaries are provided with consistent benefits.

GAO found that some of the Medicare beneficiaries who have cataract surgery later obtain multiple replacement prosthetic lenses. GAO found that, because Medicare regulations do not establish specific limits on the number of replacement lenses for which it will pay, limits among the carriers varied from stringent limits to none at all. GAO also found that physicians were receiving overly high payments for their services compared to allowed charges for other similar procedures. GAO estimates that improved guidance by the Department of Health and Human Services (HHS) could have resulted in a reduction in Medicare allowed charges of at least $7.4 million during 1982 in areas served under 7 of the program's 49 claims processing contracts.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: The Consolidated Omnibus Reconciliation Act of 1985 directed HCFA to establish separate payment amounts for the two components and apply the inherent reasonableness criteria. HCFA complied with the act's requirement.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration (HCFA) to develop and implement guidance to require that carriers establish cost-based reimbursements for prosthetic lenses and separate reasonable allowances for the professional services related to fitting cataract eyeglasses and contact lenses.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: HCFA planned to develop a uniform screen for the number of replacement contact lenses and cataract eyeglasses which emphasizes the need to apply the inherent reasonableness criteria in determining allowable reimbursement for prosthetic lenses. Effective January 1, 1986, HCFA mandated a prepayment medical necessity screen for all claims for replacement lenses.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop and implement uniform screens for the number of replacement prosthetic lenses for which Medicare payment will be made. Replacements exceeding the screens should require justification before payment is made.

    Agency Affected: Department of Health and Human Services

 

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