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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Highlights
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.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | 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. |
Closed – Implemented
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.
|
| Department of Health and Human Services | 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. |
Closed – Implemented
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.
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Topics
Health care cost controlHealth care costsHealth care servicesInternal controlsMedical feesMedicareProsthetic devicesBeneficiariesSurgeryAllowances