Opportunities To Reduce Medicare Payments Related To Cataract Surgeries While Enhancing Nationwide Uniformity of Benefits

GAO testified on its recent report which discussed opportunities for reducing Medicare payments associated with cataract contact lenses and eyeglasses and ensuring that beneficiaries nationwide are treated equally. Medicare regulations authorize reimbursements to physicians for the replacement of lost or damaged prosthetic lenses and are administered with the contracted assistance of various insurance companies called carriers. GAO found that, since the regulations do not establish limits on the number of replacement lenses that Medicare will cover and the carriers are allowed to set reasonable limits on the number of replacements, carrier administration of this benefit varies widely. GAO believes that the lack of control over the payments for replacement lenses resulted in unnecessary expenditures of Medicare funds and inequitable treatment of Medicare beneficiaries, and it recommended that the Secretary of Health and Human Services (HHS) develop and implement uniform payment screens to cover the number of replacement lenses paid under Medicare. GAO also found that physicians charge a comprehensive fee covering the lenses and fitting when billing either Medicare or the beneficiary; however, the comprehensive fees that Medicare paid were excessive for the services that were provided. GAO believes that HHS has the authority to require separate billings and recommended that the Secretary of HHS develop and implement guidelines to require cost-based reimbursement for the lenses and separate allowances for the related professional services. In comments, the Secretary stated that separate reimbursement would be considered and carriers would be advised to apply inherent reasonableness in determining reimbursement for lenses.