Medicare:

Separate Payment for Fitting Braces and Artificial Limbs Is Not Needed

HRD-93-98: Published: Jul 21, 1993. Publicly Released: Jul 21, 1993.

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Pursuant to congressional requests, GAO reviewed whether: (1) orthotic and prosthetic (O&P) practitioners should receive separate payments for their professional services in fitting patients; (2) there were items covered under the O&P fee schedule that could be moved to a more appropriate payment category; and (3) the criteria used to determine patient eligibility for O&P items were consistent across the country.

GAO found that: (1) a separate fee schedule for the O&P practitioners' professional services is not needed; (2) the current fee schedule includes a category for O&P professional services; (3) ostomy and urological supplies could be reclassified as inexpensive or routinely purchased durable medical equipment, since they do not require a significant amount of service from the supplier; (4) carriers use different medical criteria when making coverage decisions for braces and artificial limbs; (5) the Health Care Financing Administration's reduction in the number of carriers processing claims could result in the application of more consistent criteria; and (6) Medicare carriers make coverage decisions based on local medical policy and national guidance.

Matter for Congressional Consideration

  1. Status: Closed - Implemented

    Comments: In the Omnibus Budget Reconciliation Act of 1993, Congress shifted specific O&P items to the inexpensive or routinely purchased category. However, Congress did not authorize the Secretary of HHS to shift other items.

    Matter: Congress should amend the Social Security Act to permit the Secretary of Health and Human Services to reclassify items currently covered as O&P items, such as ostomy and urological supplies and certain braces that the Secretary determines do not require significant amounts of fitting and adjustments, to the fee schedule for inexpensive or routinely purchased durable medical equipment.

 

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