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Durable Medical Equipment: Specific HCFA Criteria and Standard Forms Could Reduce Medicare Payments

HRD-92-64 Published: Jun 12, 1992. Publicly Released: Jun 12, 1992.
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Highlights

Pursuant to a legislative requirement, GAO studied Medicare payments for durable medical equipment, focusing on the: (1) adequacy of the Health Care Financing Administration's (HCFA) criteria for determining medical necessity; and (2) potential of standardized certification forms for reducing unnecessary payments.

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, HCFA, to develop and issue specific coverage criteria for equipment HCFA identifies as subject to unnecessary payments.
Closed – Implemented
The four regional carriers for DME claims have developed specific medical review policies for the 100 most frequently utilized items of durable medical equipment. These policies contain detailed criteria that supplement HCFA's broad criteria.
Department of Health and Human Services The Secretary of Health and Human Services should direct the Administrator, HCFA, to require that the medical necessity certification forms being developed by HCFA for equipment subject to unnecessary payments require physicians to provide detailed narrative justification documenting the medical necessity for the prescribed equipment.
Closed – Implemented
HCFA has developed, and is continuing to develop, medical necessity forms for equipment subject to unnecessary payments. However, these forms generally do not require specific narrative justifications. Rather, they typically are composed of detailed, specific questions that can be addressed through a "yes", "no", or scale indicator response. HCFA believes that these types of forms provide carriers with specific answers to the questions that they most need addressed in order to make a claims payment determination.

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Topics

Eligibility criteriaEligibility determinationsFormsHealth care cost controlHealth insurance cost controlInsurance claimsMedical equipmentMedical expense claimsMedicareQuestionable payments