November 24, 2008
Medicare allows physicians and other providers to collect fees from patients for services that are not covered by the Medicare program if they have alerted the patients of their potential liability using an "Advance Beneficiary Notice" (ABN).
The ABN tells a patient that Medicare will probably not cover a particular procedure and that the patient will be expected to pay the full charge out of pocket. If the physician does not obtain a validly executed ABN, the practice will not be able to bill the patient if and when the claim is denied. An example of services that Medicare may not cover would be a greater number of trigger point injections than the carrier's policy allows. See, e.g., NHIC's Local Coverage Determination (LCD) #07-03.1 V9:
it is expected that trigger point injections may be performed as frequently as a monthly interval from the time of onset of illness or injury for the first three sets of injections of a treatment course, and as frequently as every two months thereafter for an additional three sets of injections. At that point, the patient should be re-evaluated regarding the etiology of the complaint, and the available treatment options reconsidered. Medicare will consider payment for additional trigger point injections upon review.
An ABN would permit the pain physician to bill the patient covered by this LCD if NHIC denied payment for a greater number or more frequent trigger point injections than NHIC considered reasonable.
A new ABN form has been available from the Centers for Medicare and Medicaid Services since March 1, 2008. This form (CMS-R-131) replaces the general-use ABN-G required since 2003. Originally its use was to have been mandatory by September 1, but since final instructions were not ready in time, the date by which physicians must begin using the approved form has been postponed until March 1, 2009.
Some frequently-asked questions about ABNs include the following:
- Does the Medicare "limiting charge" still apply or can I bill the patient my unreduced fee?
You may bill your unreduced fee. The most significant change in the ABN form is that the practice is now required to complete the "estimated cost" field, which was previously optional.
- Does the physician have to discuss the ABN and obtain the patient's signature personally?
No. The ABN is not like informed consent and the entire process of explaining its purpose and having the patient sign the form may be delegated to an employee.
- I never know whether Medicare is going to pay. Should I have all my patients fill out an ABN?
No. Medicare prohibits this practice and requires you to make a judgment. If you expect Medicare to pay, don’t use the ABN. If, however, you know that the service is simply not covered by Medicare, e.g., anesthesia for a rhytidectomy, you have the option of using the ABN, but it is not required in order for you to be able to collect from the patient.
- How much detail do I need to provide on the reasons I expect Medicare may deny payment?
According to CMS' instructions for filling out the ABN, three commonly used reasons for noncoverage are:
"Medicare does not pay for this test for your condition."
"Medicare does not pay for this test as often as this (denied as too frequent)."
"Medicare does not pay for experimental or research use tests.
- Do I need to file the ABN with Medicare?
No. You should give the patient a copy and keep a copy in your files. Remember, the purpose of the form is to document that you gave the patient notice that he or she might be personally responsible for your charges.
For the most complete information available, download the revised section of the Medicare Claims Processing Manual, Chapter 30 (Financial Liability Protections), Section 50 (Form CMS-R-131 Advance Beneficiary Notice of Noncoverage (ABN)) at http://www.cms.hhs.gov/Transmittals/downloads/R1587CP.pdf. For copies of the revised ABN form and ”Final Form Instructions 8-28-BNI.doc,” go to http://www.cms.hhs.gov/BNI/Downloads/ABNFormInstructions.zip. ABC clients should consult with their account managers to make sure that they will be ready to use the new forms, if they are not already using them. If you are not a client of ABC and would like further clarification please email us at eblast@anesthesiallc.com.
