Durable Medical Equipment

In November 1993, the Health Care Financing Administration began consolidating the work of processing and paying claims for durable medical equipment, prostheses, orthoses, and supplies at four regional carriers. Claims for such items had previously been processed and paid by local Medicare carriers. As part of the transition to regional processing, the four regional carriers developed coverage criteria for the items. GAO found that the final criteria adopted by the regional carriers are consistent will Medicare's national coverage policies and the law. GAO does not believe that the criteria have impeded disabled beneficiaries access to needed durable medical equipment and other items. Also, in 1994 the regional carriers approved a similar percentage of service for durable medical equipment and other items for disabled and aged and aged Medicare beneficiaries, so there was no significant difference in access to durable medical equipment and other items between the two groups of beneficiaries.

GAO found that: (1) the final criteria adopted by the regional carriers are consistent in all material respects with Medicare's national coverage criteria and Medicare law; (2) in 1994, the regional carriers approved durable medical equipment, prostheses, orthoses, and supplies (DMEPOS) claims for disabled Medicare beneficiaries at a similar rate as for aged beneficiaries, and there was no apparent difference in the application of the criteria between disabled and aged Medicare beneficiaries; (3) some groups representing disabled persons believe that the disabled need DMEPOS to accomodate a more active lifestyle than aged beneficiaries; and (4) the Health Care Financing Administration (HCFA) restricts coverage to standard DMEPOS items unless the beneficiary's physician prescribes and justifies lightweight materials or customized items on medical grounds, which is consistent with current Medicare law.