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HRD-84-94 1 (1984-09-27)

handle is hein.gao/gaobabnni0001 and id is 1 raw text is: tD a~hard L. 2ua UNITED STATES GENERAL ACCOUNTING OFFICE Y~uWASHINGTON, D.C. 20548 00Naut HUMAN ---------- r r.M HUMAN RESOURCES September 27, 1984 Carolyne K. Davis, Ph.D., Administrator Health Care Financing Administration Dear Dr. Davis: Subject: Reimbursing Physicians Under Medicare on the Basis of Their Specialty (GAO/HRD-84-94) Medicare regulations permit differences in prevailing rates for physician services if Medicare carriers determine there are differences in charging patterns among various physician specialties. For example, a carrier might establish $15 as the prevailing rate for a brief office visit to a general practitioner but establish this rate at $25 for a brief visit to a cardiologist. Medicare requires its carriers to compare charging patterns among physician specialities to determine if those patterns show a basis for establishing separate prevailing rates for the same procedure. The 11 carriers we reviewed, however, generally made little or no analysis in support of either multiple or single prevailing rates. Moreover, HCFA has provided no guidance to carriers on how to conduct these analyses. HCFA needs to take steps to provide assurance that carriers conduct charge pattern analyses as required and give carriers guidance on how to make such analyses. Also, Medicare permits physicians to self-designate their specialties. That is, carriers are permitted to recognize a physician in the specialty of his or her choice, irrespective of education, training, experience, or other qualifications. HCFA should establish criteria as to what constitutes a specialist for Medicare reimbursement purposes. OBJECTIVES, SCOPE, AND METHODOLOGY The objectives of this review were to examine (1) the basis for carrier prevailing rate structures, that is, the number of prevailing rates used for reimbursement purposes and (2) the (106219) 125448 l

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